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Abdominal Exam

*Chart

number: 49/13.

*G: 2

*P: 1

*GA: 33wks + 1days

**Inspection findings:When I inspect her abdomen , I found the size


appropriate with GA , the shape of her abdomen
indication that the fetal position is right occipito anterior
(ROA), linea nigra (dark line of pigmentation running
longitudinally in the central of abdomen. ) was appear, I
didnt found stria gravidarum in her abdomen, she have
scar and sign of abdominal surgery because she do CS &
Collestoctamy , the active movement of fetus was appear
and clear.

**Palpation findings:
(1)Step 1 (Fundal palpation ):Face the client head , curve my palmer surface of the
both hands , my hands are placed on her abdomen below
the xiphisternum ,and moved gentle down ward until the
firmness of fundus is felt, when I palpation her abdomen
(fundus),I found it soft ,less firm, irregular, large ,bulkier,

less clear defined ,cant move independently of trunk ,


its continuous with convex surface of the back(Buttocks).

(2)Step 2 (Lateral Palpation ):In this step , the aim is identify the fetal position &
confirm lie.
The first--- I put my hand on the right side of abdomen
and other hand put on left side to support the right
side , when I palpate the right side I found it smooth,
firm, uniformly resistant ,convex ---(Back).
Then --- I put my hand on the left side of abdomen and
other hand put on right side to support the left side ,
when I palpate the left side I found it small, irregular
placed , knobby resistances, passive movement---(Limps).

*The position :- ROA.


*The presentation:- Cephalic (vertex).
*The Lie :- longitidunal.
(3)Step3 (Pawliks grip):This method to palpating the presenting part.

I stand facing the mothers head , I grasp the full bulk


of the presenting part between my fingers , the part is
globular, smooth, ballotable (move gently from side to
side).---(The head).
The engagement 4/5 palpable.

**Combined pawlik grip:This step to compare the upper and lower poles of the
fetus at the same time.
I grasp the presenting part in one hand and grasp the
fundus in the same with the other hand , I found the fetus
butokes on the fundus and the fetus head on the
symphasis bubis.

(4)Step 4 (pelvic palpation):Using both hands , one either side of the presentation(
finers facing toward the women feet ) press in gently .
The head cant felt easily ,and it can movable between
the fingures , I assurance that the presenting is vertex
,the fetus is pelvic , the presenting part is engaged and
movable between my hand .

**Fundal height:-

When I assess fundal height I use measure tap , I put


the measure tap from the upper border of the symphysis
Pubis to the top of fundus, along midline of the
abdomen , I found the fundal height equal the GA=34cm
this means S=D .

**Auscultation findings :When I observe fetal heart by sonicades the fetal


heart is clear ,the heart sounds are heard through the
fetal shoulder (scapula), the fetal heart is regular , normal
, rate 133 b/m, heard on the anterior.

( Souffls ):The placenta sound heard at time of fetal hearts.

Number of antenatal visits:Visit


date

Risk
scor
e

GA

23High 16
12Risk wk
2014
+6
dy
24-1- High 21
2015 Risk wk
+3
dy
24-2- High 25
2015 Risk wk
+6
dy
25-3- High 30
2015 Risk wk

W(k BP
g)

Oed Bleedin Fund


ema g
al
heig
ht
No
No
19

presentati Feta
on
l
hea
rt
Yes

82

120/
71

82

128/
80

No

No

21

Yes

85

126/
79

No

No

25

Yes

85,
5

118/
61

No

No

30

Cephalic

Yes