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Midwifery lore
& abdominal assessment
Lorna Davies
Over the course of the next few months, I intend to present a series of
articles which harness the wisdom and experience of midwives in order to
explore a range of midwifery practice skills and knowledge. The series aims
to identify what midwives know and practise, and this may or may not reflect
current evidence-based recommendations, or may sometimes appear to
challenge them. However, the remit of this series is not to critique the
research evidence but to listen to the voices of practising midwives.
he word ‘lore’ may seem anachronistic but it serves the purpose of this series perfectly as it is defined as
‘knowledge gained through tradition or anecdote’ (The Free Dictionary 2010). In this age of information
technology and virtual experience, the slower pace of the apprenticeship process may be viewed by
some as a dated way of learning, but for many of us, the lessons learnt by ‘sitting next to Nellie’ remain with us
for life. Most of us have memories of positive role models who influenced our practice by sharing their
wisdom and know-how.
T
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Essentially MIDIRS • October 2010 • Volume 1 • Number 4
Sitting next to
Nellie
During the planning stage of this series, I was keen to gather
thoughts and skill sharing opportunities from as diverse a
group as possible. I contacted a range of midwives and asked
them for any information that they would be willing to share,
and the results are set out in this article. For subsequent topics
in the months ahead, the discussion will be facilitated using an
online conference platform to bring tradition and technology
together in an exciting and innovative way. You can find more
information about this concept and how you can become
involved in the September edition of Essentially MIDIRS on p26.
This month we will look at the subject of abdominal
assessment during pregnancy and call upon the knowledge
and practical advice of midwives from a number of
different countries.
Abdominal Assessment
Before approaching midwives for their thoughts on the subject,
I decided to look at the textbooks that outline the practice to
establish how the assessment is defined. With the exception of
a few authors such as Elizabeth Davis (1997) and Celia Grigg
(2006), the majority of textbook teachers seem to be of the
opinion that the assessment, and in particular the palpation, is
performed almost exclusively to confirm the continuing growth
and well-being of the baby. If the woman is mentioned, it is
usually in relation to shielding her from worry.
However, as the midwives in this article illustrate with their
words, the assessment facilitates a much more complex
function than the perfunctory role of ‘fetal surveillance’. It would
seem that the emphasis on this solitary focus diminishes the
significance of the event to a reductionist clinical procedure
instead of the holistic event that the midwives here describe.
As students, most of us were taught that the stages of
abdominal assessment include, ‘inspection, palpation and
auscultation’. Perhaps an update of this should include:
• Explanation – information sharing and gaining consent
• Observation – general observation of the woman and
specifically of the abdomen
• Palpation – lie, attitude, position, presentation,
denominator, engagement, fundal height
• Auscultation - of fetal heart
• Revelation – sharing findings with the woman
• Documentation.
I will use these stages to work through the contributions of the
midwives who informed the discussion.
Explanation
Suggesting that the woman should be offered an explanation
of what the procedure involves and why it is performed may
feel like stating the obvious. However, it is recognised that
many of the things we do and say in practice can become so
commonplace that it is easy to lose sight of their significance
for the woman (Edwards 2005). At this point it is easy to
assume that women will accept abdominal examination as part
of the antenatal appointment, willingly and unquestioningly.
However, how can we gain informed consent if we do not offer
an explanation beforehand?
‘When I approach undertaking a palpation I first ask the mother if I
may touch her belly’.
Asking the woman’s consent before touching her may appear
commonsensical but Olsen (1999) highlighted that women
frequently report feeling excluded from the procedure.
Engaging the woman in discussion prior to carrying out the
assessment also acknowledges her tacit knowledge about
her baby.
‘I always, always ask the mother things like where do you feel kicks,
wriggles etc and where do you think baby is lying, has it moved?’
Discussion with the woman may also help to identify factors
that can then be confirmed or otherwise during palpation.
‘I always talk to the woman first. Lots of movement around the
cervix with the feeling that she has something under her rib that
she needs to move always indicates a breech. Areas without
movement which the woman will often mention is an anterior
placenta nicely heard when checked with Pinard.’
Observation
As with so many areas of practice, the value in
observing before laying on hands, cannot be
overemphasised for early gathering of
information. The word ‘observe’ feels
a little more circumspect than
the word ‘inspect’, and
somehow results in
moving the
spotlight
Essentially MIDIRS • October 2010 • Volume 1 • Number 4
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Sitting next to
Nellie
from the gravid uterus to the
pregnant woman.
Jean Sutton (2001) suggests looking at the
shape of the woman’s belly as she walks into the
room. She advocates that a woman who is carrying
her baby in an occiput posterior position will have a
tight and high abdomen, whereas the baby lying in an
occiput anterior and whose head is well down in the pelvis will
create an appearance which is lower and rounder.
Closer observation, as the woman presents her belly for
palpation, introduces the opportunity to glean a further range
of information. Acronyms, mnemonics and other prompts are
always popular and the 4 or sometimes 5 S’s, which most of us
are familiar with, were mentioned by several of those
interviewed. Interestingly, these varied between individuals.
‘I observe the mother's belly for the five S's - shape, size, scars, striae
and saucer (the umbilical saucer shape denoting OP position)’.
Others mentioned skin (rashes, bruising) and one additional S
was squirming, that is observing the baby’s movements in later
pregnancy! So perhaps we should revise this aide-memoire to
incorporate the 7 S’s.
‘Yesterday I checked a woman and she had a burn on her belly.
She said she misjudged and spilled a bit of hot water from a teapot
on herself. We must remember to tell pregnant woman in their last
trimester that their bellies are sticking way out there in front of them
and to be careful.’
Palpation
The midwives participating in the discussion identified that the
procedure offered a ‘window to the womb’ which went so much
further than monitoring fetal growth.
‘Abdominal palpation is way more than fetal surveillance. It is also
about connection with the baby’s energy, how the baby responds
to touch, the vitality in its positioning…..for me it is very much
about connection.’
The midwives unanimously agreed that the tactile skills that lie
within our hands are an essential part of our toolkit and that we
should keep these skills finely honed lest we should lose them.
‘For me, the most important aspect of palpation is learning to "see"
with my hands. My fingertips are like sensitive radars that can
imagine the position of the baby.’
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Essentially MIDIRS • October 2010 • Volume 1 • Number 4
This midwife stated that in order to learn how to appreciate the
value of the sensitivity of their touch,
‘…student midwives should explore objects with their hands while
closing their eyes or practise feeling the face of a loved one, while
their eyes are closed.’
The actual practice of carrying out the palpation was described
by the responding midwives in fairly uniform terms, with the
practitioners using the textbook series of movements (known
to our US colleagues as the Leopold manoeuvres) to ascertain
lie, position, and so on.
‘Identify the fetal poles, and determine the lie. Apply pressure on one
side and gentle firm palpation with the other. Then locate the fetal
back in relation to maternal right or left. I use a two handed
identification of descent, and only use Pawlik’s grip if I am unable to
identify presentation.’
‘I guestimate size based on visuals and where the top of uterus is
according to established norms - you know 30 weeks between
umbilicus and xyphisternum and 36 at xyphisternum etc. I use a
tape measure (wrong side up) and feel for pubic bone (the top of
uterus already determined) and make sure that there is no bowel
etc in way of fundus.’
The two issues that generated the most interest for the
midwives were the issues of measuring fundal height and
establishing engagement. The debate around fundal height
hinged around whether to use ‘landmarks’ to gauge gestational
age, or a tape measure. It was identified that using a tape
measure may have some value where continuity of care is not
available, but that it was important to recognise that women
come in many different shapes and sizes and a one size fits all
approach can therefore be misleading.
‘A petite lass of 4ft 11 and a robust woman of 5ft 10 are never going
to measure the same. That’s just common sense.’
‘I use landmarks because I believe that a woman's torso length and
her pelvic shape etc can result in so many deviations from the norm
that I do not want to use a technique which may be yet another
stick with which to beat women!’
‘Despite what the Grow Programme states, the measurements will
decrease once the head engages and the fetal growth is normal.’
The unengaged head at term is something that we know can
have a fairly major influence on outcome. This may be because
the evidence suggests that a nulliparous woman whose baby
has not entered the pelvis at term does appear to have an
Sitting next to
Nellie
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increased risk of caesarean section (Debby et al 2003). However,
who is to say that the concern generated for the woman, on
the part of the practitioner, does not contribute to this?
Perhaps a more laid-back attitude could help to decrease
the risk.
‘I tend not to worry about a large head diameter entering the pelvis
as often that head is a little transverse just before labour. I think that
once that baby has just turned its head a little into the transverse
diameter the woman goes into labour. Anterior or posterior it's that
slight change into the transverse for a woman with a gynecoid
pelvis that indicates labour is close.’
‘If head is high and she is close to term, ask the woman to come
up onto her elbows to see how baby's head goes into pelvis when it does, affirm [to the woman] that there is plenty of room
for baby's head to engage because someone has usually said
something negative before you got there and you can do some
damage limitation.’
Auscultation
The midwives talked about using different types of auscultatory
methods according to the situation that they are in. These
included pinards, fetoscopes and hand held electronic
monitors. Currently the value of listening routinely to the fetal
heart during antenatal appointments is being challenged, and
not without a reasonable rationale (NICE 2008). However
several of the midwives indicated that they used listening to
the fetal heart as a further opportunity to help the woman (and
her partner/children) to make a connection with the baby.
‘If using a pinard I usually offer the father a chance to listen too,
though it is often difficult to hear for them. If I am using the fetal
stethoscope, once I have located the FH and it is reassuring, I pass the
ear-pieces to the mother for her to hear too. I just LOVE the secret
smile that spreads across women’s faces when they realise they are
listening to the actual heartbeat, not some machine construct!’
On a less personal note, one of the midwives reported:
’…it seems like so many women are buying their own sonicaid type
devices now, that I feel that I have to listen to the FH either to stop
them buying one or to ensure that they using it properly.’
Revelation
There are a number of ways in which feedback can be given to
the woman. Many of the midwives talked about involving the
woman and her family in the process by getting them to
palpate the baby, with guidance.
‘I ask the woman if I can place my hands on hers and I gently guide
her so she too can feel how her baby is lying. It’s a journey of
discovery and the womens’ faces light up. I do the same for the
partner if they are there.’
By getting the woman to do this and concurrently giving an
explanation of what she is feeling, we are probably giving the
best possible feedback. Some of the midwives utilise models to
give feedback.
‘I use one of the pocket sized doll and pelvises to show how the baby
is lying or I lie a doll on the woman’s abdomen to show position of
baby and how far they are engaged.’
Some of the more artistic even draw little images for
the women.
‘I draw a little picture in the notes after every visit. The women really
seem to like it. And it gives them a better understanding.’
Documentation
This section is fairly self-explanatory, but as a midwife teacher I
always welcome the introduction of good prompts and
activities to teach student midwives that they need to use a
methodical way of recording detail without losing the less
tangible aspects of the procedure. One such tool is the
LAPPED acronym:
• Lie
• Attitude
• Presentation
• Position
• Engagement
• Denominator.
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Sitting next to
Nellie
Conclusion
It would seem that the traditional
approach to abdominal assessment by
observation, palpation and auscultation is
currently under scrutiny as a reliable form of appraisal.
The increases in antenatal screening tests and in fetal
biophysical profiling methods profess to offer more reliable
forms of fetal surveillance (NICE 2008). If we subscribe to the
view that the principle, if not the sole reason, for performing
abdominal assessment is fetal monitoring, then the potential
for a decline in our skills would seem to be inevitable. If
however, we view the practice as a holistic one which amongst
other things facilitates the relationship between a woman and
her baby, educates the woman and her partner about aspects
of the pregnancy and gives joy to her family, and of course the
midwife, then we need to preserve and promote the practice.
The midwives who participated in this discussion and
contributed their thoughts and practice traits, bear witness
to the fact the whole is greater than the sum of its parts.
Abdominal assessment could be seen to embody the art of
midwifery and perhaps even the personality of the midwife.
Bearing that in mind, I will leave you with the words of a
midwife who spoke of a woman whose antenatal care was
shared between three practitioners.
‘She described the different ways that we palpated her baby. Janet
was a gentle soul and her touch felt like a light wind. Gemma’s
touch had a musical quality like a song. Mine she described as a
purposeful and pragmatic. We all gave something of ourselves
during that hands-on experience.’
Participating Midwives
Maggie Banks, New Zealand
Lisa Barrett, Australia
Mary Cronk, UK
Carolyn Hastie, Australia
Pamela Hunt, US
Jill Hutchings, UK
Dawn Jacobs, New Zealand
Sue Kinross, UK
Janice Marsh-Prelesnik, US
Liz Nightingale, UK
Sarah Pallet, New Zealand
Silke Powell, New Zealand
Debs Purdue, UK
Julie Richards, New Zealand
Debra Saund, UK
Alys Sillett, UK
Lorraine Wall-Jones, UK
Davis E (1997). Heart and hands: a midwife's guide to pregnancy and birth. 3rd ed.
Berkeley, California: Celestial Arts.
Debby A, Rotmensch S, Girtler J et al (2003). Clinical significance of the floating fetal
head in nulliparous women in labor. Journal of Reproductive Medicine 48(1):37-40.
National Institute for Health and Clinical Excellence (2008). Antenatal care: routine
care for the healthy pregnant woman. London: NICE. http://www.nice.org.uk/
guidance/index.jsp?action=byID&o=11947 [Accessed 6 July 2010].
Olsen K (1999). `Now just pop up here, dear...' Revisiting the art of antenatal
abdominal palpation. Practising Midwife 2(9):13-15.
Edwards NP (2005). Birthing autonomy: women's experiences of planning home births.
New York: Routledge
Sutton J (2001). Let birth be born again!: rediscovering and reclaiming our midwifery
heritage. Bedfont: Birth Concepts.
Grigg C (2006). Working with women in pregnancy. In: Pairman S, Pincombe J,
Thorogood C et al. Midwifery preparation for practice. New South Wales: Elsevier.
The Free Dictionary (2010). Lore. http://www.thefreedictionary.com/lores [Accessed
15 July 2010].
Lorna Davies
RM, BA(Hons), MA, PGCE(A)
Lorna Davies is a UK qualified midwife who has worked in midwifery education for the last fifteen years. She has been widely
published and has edited several midwifery textbooks. She is currently working as a Principal Lecturer in Midwifery at CPIT in
Christchurch, New Zealand, and carries a small midwifery caseload.
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