OSCE: Obstetric Exam

Question 1

What should your introduction include in an obstetrics exam?

Answer 1

1) Wash your hands and don PPE if appropriate.

2) Introduce yourself to the patient including your name and role.

3) Confirm the patient’s name and date of birth.

4) Brief explanation

5) Offer chaperone

6) Gain consent

7) Position patient with the head of the bed at a 30-45° angle for the initial assessment.

8) Adequately expose the patient’s abdomen for the examination from the pubic symphysis to the xiphisternum (offer a blanket to allow exposure only when required).

9) Provide the patient with the opportunity to pass urine before the examination.

10) Ask the patient if they have any pain before proceeding with the clinical examination.

Question 2

Example brief explanation for obstetric exam:

Answer 2

“Today I need to examine your tummy as part of the assessment of your pregnancy. This will involve me looking and feeling the tummy, in addition to performing some measurements. Although it may be a little uncomfortable, it shouldn’t be painful. If at any point you’d like me to stop then please just let me know.”

Question 3

Overview of strcuture of obstetrics exam?

Answer 3

1) Introduction

2) General inspection:
- clinical signs
- objects & equipment

3) Hands
- inspection
- temperature
- CRT
- radial pulse

4) Face
- inspection

5) Abdominal inspection
- positioning
- inspection

6) Abdominal palpation:
- abdomen
- uterus
- fetal lie
- fetal presentation
- fetal engagement
- symphyseal-fundal height

7) Foetal heartbeat

8) Conclusion & summary
- future investigations: urine dipstick & BP

Question 4

What ‘clinical signs’ are you looking for during general inspection?

Answer 4

1) Pain: if the patient appears uncomfortable, ask where the pain is and whether they are still happy for you to examine them.

2) Obvious scars: may provide clues regarding previous abdominal surgery (e.g. caesarian section)

3) Pallor

4) Jaundice

5) Oedema

Question 5

What may pallor indicate?

Answer 5

Underlying anaemia

Note - healthy individuals may have a pale complexion that mimics pallor.

Question 6

What may jaundice indicate?

Answer 6

High bilirubin e.g. due to obstetric cholestasis

Question 7

When is oedema during pregnancy normal?

Answer 7

A small amount of oedema is normal in the later stages of pregnancy

Question 8

What may widespread oedema affecting the arms, legs and face indicate?

Answer 8

Pre-eclampsia

Question 9

What objects & equipment are you looking for during general inspection?

Answer 9

1) Mobility aids

2) Vital signs e.g. BP

3) Fluid balance

4) Prescriptions

Question 10

What is obstetric cholestasis?

Answer 10

A multifactorial condition that is characterised by abnormal LFTs function tests, jaundice and intense pruritis (typically affecting the palms and soles of the feet).

The disease usually presents in the third trimester and is associated with an increased risk of intrauterine death and premature delivery.

Question 11

What triad is seen in obstetric cholestasis?

Answer 11

1) Abnormal LFTs

2) Jaundice

3) Intense pruritus (typically affecting the palms and soles of the feet)

Question 12

Which trimester does obstetric cholestasis usually present during?

Answer 12

3rd trimester

Question 13

What complications is obstetric cholestasis associated with?

Answer 13

1) increased risk of intrauterine death

2) premature delivery

Question 14

What is involved in assessment of the hands in an obstetric exam?

Answer 14

1) Inspection

2) Temperature

3) CRT

4) Radial pulse

Question 15

What are you looking for during inspection of the hands?

Answer 15

1) Pallor: pale or cyanosis

2) Peripheral oedema e.g. pre-eclampsia

3) Palmar erythema

Question 16

What may pale hands suggest in pregnancy?

Answer 16

Pale hands suggest poor peripheral perfusion (e.g. hypovolaemic shock, aortocaval compression) and cyanosis may suggest underlying hypoxaemia.

Question 17

If pre-eclampsia is suspected, what investigations are indicated?

Answer 17

BP & urinalysis (looking for proteinuria)

Question 18

What is palmar erythema?

Answer 18

A redness involving the heel of the palm that is a normal finding in pregnancy.

Question 19

What may cool hands suggest in pregnancy?

Answer 19

Cool hands may suggest poor peripheral perfusion (e.g. hypovolaemic shock, aortocaval compression).

Question 20

What may an increased CRT indicate in pregnancy?

Answer 20

A CRT that is greater than 2 seconds suggests poor peripheral perfusion (e.g. antepartum haemorrhage, aortocaval compression) and the need to assess central CRT.

Question 21

If CRT is prolonged, what is indicated next?

Answer 21

Assess central CRT

Question 22

How is HR affected in pregnancy?

Answer 22

Women typically have a higher baseline heart rate during pregnancy (80-90 beats per minute).

Question 23

How to look for jaundice in the face?

Answer 23

It is most evident in the superior portion of the sclera (ask the patient to look downwards as you lift their upper eyelid).

In the context of an obstetric abdominal examination, it is most likely secondary to obstetric cholestasis.

Question 24

What is jaundice most likely 2ary to in an obstetric exam?

Answer 24

Obstetric cholestasis

Question 25

What is melasma?

Answer 25

Benign dark and irregular hyperpigmented macules which are normal in pregnancy.

Question 26

When positioning a pregnant patient for an abdominal exam, the recommended positioning varies depending on the current gestation.

What is the positioning for early pregnancy?

Answer 26

Position the patient supine on the couch, with the head end of the bed elevated to 15-30°.

Question 27

What is the positioning for an abdo exam during late pregnancy?

Answer 27

Position the patient in the left lateral position (tilted 15° to the horizontal level) to avoid compression of the abdominal aorta and inferior vena cava by the gravid uterus (known as aortocaval compression).

Question 28

Why should patients who are in the later stages of pregnancy be positioned in the left lateral position (tilted 15° to the horizontal level)?

Answer 28

To avoid compression of the abdominal aorta and inferior vena cava by the gravid uterus (known as aortocaval compression).

Question 29

What are you closely inspecting the abdomen for?

Answer 29

1) Abdominal shape: may give an initial indication of the fetal lie.

2) Foetal movements: typically visible from 24 weeks gestation.

3) Surgical scars: may provide clues regarding previous abdominal surgery (e.g. caesarian section).

4) Linea nigra

5) Striae gravidarum

6) Striae albicans

Question 30

What is the linea nigra?

Answer 30

A dark line running vertically down the middle of the abdomen (a normal finding in pregnancy).

Question 31

What are striae gravidarum?

Answer 31

Reddish or purple lesions that develop due to overstretching of the abdominal skin as the gravid uterus expands (commonly referred to as stretch marks).

Question 32

What are striae albicans?

Answer 32

Mature stretch marks which appear silver-like in colour and are less pronounced.

Question 33

What is aortocaval compression syndrome?

Answer 33

This occurs due to compression of the abdominal aorta and inferior vena cava by the gravid uterus when a pregnant woman is supine.

Can result in maternal hypotension, loss of consciousness and in rare cases fetal demise.

Question 34

How can the risk of aortocaval compression syndrome be reduced?

Answer 34

Women in late pregnancy are positioned in the left lateral position when supine to reduce pressure on the aorta and inferior vena cava.

Question 35

What are the steps for abdominal palpation?

Answer 35

1) Palpate the abdomen: light palpation over each of the nine regions of the abdomen to identify any tenderness or masses that may not relate to the pregnancy (e.g. appendicitis)

2) Palpate the uterus

3) Fetal lie

4) Fetal presentation

5) Fetal engagement

6) Symphyseal-fundal height

Question 36

Purpose of palpating the uterus?

Answer 36

Palpate the uterus to identify its borders, including the upper and lateral edges.

Question 37

The uterine fundus can be found at different locations during pregnancy, depending on the patient’s current gestation.

Where is it found at:
a) 12 weeks
b) 20 weeks
c) 36 weeks gestation?

Answer 37

a) pubic symphysis

b) umbilicus

c) xiphoid process of sternum

Question 38

What is the fetal lie

Answer 38

Fetal lie refers to the relationship between the long axis of the fetus with respect to the long axis of the mother.

Question 39

How can the fetal lie be determined?

Answer 39

Assess the gravid uterus to determine the fetal lie:

1) Place your hands on either side of the patient’s uterus (ensuring you are facing the patient).

2) Gently palpate each side of the uterus:
a) One side of the uterus should feel full in nature (due to the presence of the fetal back).
b) On the other side of the uterus, you may be able to feel the fetus’s limbs.

Question 40

What are the 3 main types of fetal lie?

Answer 40

1) Longitudinal lie (normal)

2) Oblique lie

3) Transverse lie

Question 41

What is a longitudinal lie?

Answer 41

When the head and buttocks are palpable at each end of the uterus.

Question 42

What is an oblique lie?

Answer 42

When the head and buttocks are palpable in one of the iliac fossae

Question 43

What is a transverse lie?

Answer 43

When the fetus is lying directly across the uterus.

Question 44

Define fetal presentation

Answer 44

Fetal presentation refers to which anatomical part of the fetus is closest to the pelvic inlet.

Question 45

Fetal presentation vs fetal lie?

Answer 45

Lie – the relationship between the long axis of the fetus and the mother.

Presentation – the fetal part that first enters the maternal pelvis.

Position – the position of the fetal head as it exits the birth canal.

Question 46

How can the fetal presentation be determined?

Answer 46

Assess the gravid uterus to determine fetal presentation:

1) Ensure you are facing the patient to observe for signs of discomfort and warn the patient this may feel a little uncomfortable.

2) Place your hands either side of the lower pole of the uterus, just above the pubic symphysis.

3) Apply firm pressure to the uterus angled medially, palpating for the presenting part:

a) A hard round presenting part is suggestive of a cephalic presentation (normal).

b) A broader, softer, less defined presenting part (i.e. the fetal bottom or legs) is suggestive of a breech presentation (abnormal).

Question 47

When is the fetus said to be ‘engaged’?

Answer 47

A fetus is considered ‘engaged’ when more than 50% of the presenting part (usually the head) has descended into the pelvis.

Question 48

How is fetal engagement assessed?

Answer 48

The fetal head is divided into fifths when assessing engagement:

1) If you are able to feel the entire head in the abdomen, it is five fifths palpable (i.e. not engaged).

2) If you are not able to feel the head at all abdominally, it is zero fifths palpable (i.e. fully engaged).

Question 49

Define the symphyseal-fundal height

Answer 49

Symphyseal-fundal height is the distance between the fundus and the upper border of the pubic symphysis.

After 20 weeks gestation, the symphyseal-fundal height should correlate with the gestational age of the fetus in weeks (+/- 2cm).

Question 50

After 20 weeks gestation, what should the symphyseal-fundal height correlate with?

Answer 50

The gestational age of the fetus in weeks (+/- 2cm).

Question 51

How do you measure the symphyseal-fundal height?

Answer 51

1) Begin palpation of the abdomen just inferior to the xiphisternum using the ulnar border of your left hand.

2) Locate the fundus of the uterus (a firm feeling edge at the upper border of the bump).

3) Once the fundus has been identified, locate the upper border of the pubic symphysis.

4) Measure the distance between the upper uterine border and the pubic symphysis in centimetres using a tape measure. The distance measured should correlate with the gestational age in weeks (+/- 2cm).

Question 52

How can bias be avoided when measuring the symphyseal-fundal height?

Answer 52

To avoid bias, it’s best to place the tape measure facing down and only turn to view the numbers once in position.

Question 53

How can you identify the fetal heartbeat?

Answer 53

Using a Pinard stethoscope (or a Doppler ultrasound probe).

Question 54

How can the foetal heartbeat be located & identified?

Answer 54

1) Based on your assessment of the fetus’s position, you should place the Pinard stethoscope aiming between the fetal shoulders on the fetal back.

2) Palpate the patient’s radial pulse (i.e. maternal pulse).

3) Place your ear to the Pinard and take your hand away (so the Pinard is held against the abdomen using your ear only):
- You should be applying gentle pressure, to ensure a good seal between your ear and the Pinard, as well as between the Pinard and the abdomen.
- Pressing too hard will be uncomfortable for the patient and pressing too softly will make it difficult to hear anything at all.

4) Listen for the fetal heartbeat

Question 55

If the maternal pulse coincides with the pulse you can hear, what is most likely happening?

Answer 55

You are most likely listening to the flow through the uterine vessels, rather than the fetal heartbeat.

Question 56

What further investigations may be done after an obstetric exam?

Answer 56

1) Assessment of the fetal heartbeat: using a Pinard stethoscope or Doppler ultrasound.

2) Blood pressure measurement: to assess for evidence of hypertension (e.g. pre-eclampsia).

3) Urinalysis: to assess for evidence of proteinuria (pre-eclampsia) and urinary tract infection.

4) Speculum examination: if there are concerns about vaginal bleeding or premature rupture of membranes.

7) Weight and height measurement

6) Ultrasound scan: to assess the position and wellbeing of the fetus.