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Antenatal Care Module: 11. Assessing the Fetus

Study Session 11  Assessing the Fetus

Introduction

In this study session, we turn our attention to the physical examination of the mother in order to find out about the position and health of her baby. You will learn how to examine the mother’s abdomen in order to determine whether the fetus is lying head up, head down, or sideways in her uterus. Listening to the fetal heartbeat can also give you information about the baby’s position and its wellbeing. At the end of the study session we guide you about what to do if you suspect that the baby’s position may lead to a difficult or dangerous birth, or if you suspect the woman may be having twins.

Learning Outcomes for Study Session 11

When you have studied this session, you should be able to:

11.1  Define and use correctly all of the key words printed in bold. (SAQ 11.1)

11.2  Know how to identify normal and abnormal lie of the fetus using palpation and auscultation. (SAQs 11.1 and 11.2)

11.3  Know how to assess fetal well-being by auscultation and fetal kick. (SAQs 11.1, 11.3 and 11.4)

11.4  Identify fetal conditions that require referral to the nearest health centre. (SAQ 11.4)

11.1  Finding the baby’s position in the uterus

The position of the baby in the uterus is known as the fetal lie. The purpose of finding the fetal lie is to identify whether there are any danger signs that could make labour and delivery difficult and put the mother and baby at risk.

Healthy signs

  • There is only one baby in the uterus.
  • The baby is head down at the time of birth.

Warning signs

  • The baby is feet or bottom down at the time of birth.
  • The baby is lying sideways at the time of birth.
  • The mother has twins or triplets. You already know how to listen for two fetal heartbeats (Study Session 10).

There are two methods for finding the baby’s position — feeling the mother’s abdomen (palpation), and listening (auscultation) to where the fetal heartbeat is strongest. You may need to use both methods to be sure of the position of the baby.

Auscultation is pronounced ‘oss kool tay shun’.

11.2  Feeling the mother’s abdomen

It may be difficult to find the position of the baby before the sixth or seventh month of gestation, and it is not important until 36 weeks (eight months) because it is normal for the baby to move around until the final month. Once the pregnancy is at six or seven months, it will be easier to feel the baby and find its position in the uterus.

To begin, help the mother lie on her back and give her support under her knees and head. Make sure she is comfortable. The questions you are trying to answer when you examine her are:

  • Is the baby vertical (up and down)? This is known as a vertical lie.
  • Or is it lying sideways across her belly? This is a transverse lie.
  • Is the baby facing the mother’s front, or her back?
  • Is the baby head down (cephalic presentation) or bottom down (breech presentation)?

11.2.1  Is the baby vertical?

Most babies are lying vertically by the seventh month, with the baby’s head towards the cervix of the uterus. This is the safest position for a normal delivery. To find out if the baby is vertical, lay one hand flat on each side of the mother’s abdomen. Press in gently but firmly, first with one hand, and then with the other (Figure 11.1a). Check the shape carefully. Do the ends of the baby seem to be in the mother’s sides (Figure 11.1b)? If so, the baby is probably lying sideways. Many babies lie sideways in the first months, but most turn head down by eight months or so. Babies cannot be born through the vagina from the sideways position. A baby that is sideways and cannot be turned when labour starts must be born by caesarean surgery in a hospital.

Important!If the baby is lying sideways after eight months’ gestation, refer the woman to a Health Centre.

Feeling a mother’s belly. (a) is vertical, head or bottom down. (b) is horizontal, head or bottom on the sides
Figure 11.1 (a) Feel the mother’s belly with your hands on each side, pushing gently with each hand in turn. You should be able to feel the baby lying vertically — ideally head down. (b) If the baby is lying sideways, you can usually feel its head and bottom in the mother’s sides.

It can be difficult to feel the position of the baby if the mother has very strong muscles on her abdomen, or if she has a lot of fat on her abdomen. If you have a hard time feeling the position, ask the mother to take a deep breath and let it out slowly, and to relax her body as you palpate (feel) her abdomen.

11.2.2  Is the baby facing the mother’s front, or her back?

Next, feel the mother’s abdomen for a large, hard shape (the baby’s back). If you can feel it (Figure 11.2a), the baby is facing the mother’s back. If you cannot feel the baby’s back, feel for a lot of small lumps (Figure 11.2b). If you feel a lot of small lumps instead of a large, hard shape, it probably means that you are feeling the baby’s arms and legs, which tell you that it is facing the mother’s front.

(a) shows the baby facing towards the mother’s back. (b) shows the baby facing towards the mothers front
Figure 11.2  (a) If you can feel a large hard lump, the baby is facing towards the mother’s back. (b) If you can feel a lot of small lumps, the baby is facing towards the mother’s front.

11.2.3  Is the baby head down or bottom down?

(a) Cephalic presentation (head down). (b) Breech presentation (bottom down)
Figure 11.3  (a) Cephalic presentation. (b) Breech presentation.

By the last month before birth, most babies are lying with their head towards the cervix of the uterus (Figure 11.3a). The head down position is called a cephalic presentation, and if the part of the fetal skull called the vertex comes down the birth canal first, it is the easiest presentation for childbirth. Doctors and midwives refer to the part of the baby that is pointing into the cervix of the uterus as the presenting part. In Figure 11.3a, the presenting part is the baby’s head, and in Figure 11.3b, the presenting part is the baby’s bottom. You will learn about other presentations (face, brow, shoulder) in the Module on Labour and Delivery Care.

  • Which part of the fetal skull is the vertex? (Think back to Study Session 6. You may wish to look again at Figure 6.5, which shows the bones of the fetal skull.)

  • The vertex is the area of the fetal skull midway between the anterior fontanel (the space between the bones at the front of the baby’s head), and the posterior fontanel (the space between the bones at the back of the baby’s head).

11.2.4  Feeling for the baby’s head

A health worker feeling the top of a mother’s pubic bone
Figure 11.4  Finding the mother’s pubic bone with your fingers.

By the seventh or eight month, the baby’s head has usually moved down in the mother’s pelvis. Here is how to feel for the baby’s head:

1  Find the mother’s pubic bone with your fingers. You can feel it just under the skin under the mother’s pubic hair (Figure 11.4).

2  As she breathes out, press deeply just above her pubic bone (see Figure 11.5). Be gentle and stop if you hurt her. If you feel a round, hard object that you can move a little from side to side, it is probably the back or side of the baby’s head.

If you do not feel anything in the mother’s lower belly, the baby may be lying sideways.

Pressing fingers firmly just above the pubic bone to feel the baby’s head
Figure 11.5  Press firmly with your fingers just above the pubic bone to see if you can feel the baby’s head.

3  If the shape is not clearly round, it may be the baby’s face or the baby’s bottom that you can feel. Or sometimes the baby’s bottom is up, but the head is not straight down (Figure 11.6a and b). The head may be bent to the side, or the chin may be up (Figure 11.6c). These could be signs that the baby will not fit through the mother’s pelvis at birth.

(a) baby facing the mother’s back. (b) baby facing the mother’s front. (c) baby with its chin up
Figure 11.6  If the baby is lying vertically and head down, but you can’t feel the baby’s head, it may be bent to the side (a) facing the mother’s back, (b) facing her front, or (c) with its chin up.

4  If the lower part of the baby is not too deep in the mother’s pelvis, try moving that part of the baby from side to side, using gentle rocking movements with your hands on either side of the lower part of her abdomen (Figure 11.7). If moving the lower part of the baby makes its whole back move, then the baby may be breech. If the back does not move, then the baby may be head down.

Pubic symphysis
Figure 11.7 If the baby’s back does not move when you ‘rock’ the lower part of the abdomen, then the baby may be head down.

5  Now feel the top of the mother’s uterus (the fundus), just below her ribs. Does it feel round and hard, like a head? Or is it a different shape — like a bottom, a back, or legs? If the top of the uterus feels more like a head than what you felt in the mother’s lower belly, the baby may be breech.

6  Put one hand on the baby’s back. At the same time, with your other hand, push the top end of the baby gently sideways (Figure 11.8). If the whole of the baby’s back moves when you move the top end, the baby is probably in the head-down position (Figure 11.8a). If the back stays where it is while you move the upper part of the baby (Figure 11.8b), you may be moving the head. This is because the neck can bend while the back stays in place. If you are moving the head at the top of the uterus, then the baby is breech.

(a) baby is head down. (b) baby is breech
Figure 11.8  (a) If the baby is head down, then you should be able to move its whole back by gently pushing the top of the baby sideways. (b) If you can move the top of the baby without moving its back, then it is probably in the breech position.

7  When you check the baby’s position, you might think you feel two heads or two bottoms. The mother may have twins.

  • Think back to Study Session 10. What should you do if you suspect that a woman is having twins?

  • Refer the mother to a health centre immediately.

11.2.5  Asking the mother about the baby’s kicks

Doctors and midwives refer to fetal kick (not kicks) as an indicator of fetal wellbeing, and it may also indicate the fetal lie.

As you feel the mother’s abdomen, try to imagine the different positions the baby might be in. Imagine where the baby’s hands and legs might be. Imagine how each position would feel to the mother when the baby kicks. Then ask the mother where she feels the strongest kicks and where she feels smaller movements. Is this where you think the legs and hands probably are (see Figure 11.9)?

Feet and knees make big kicks. Hands make smaller movements.
Figure 11.9  The place where the mother feels the strongest kicks may tell you the position of the baby’s feet and legs.

Important!Refer the woman to a health centre if she no longer feels the baby kicking inside her.

If the baby is healthy and getting adequate nutrients from the mother, it moves in the uterus in such a way that the woman feels it as a kick. Fetal kick is often clearly felt after the mother has eaten a meal, and when she has rested very well and is lying on her side.

If the woman tells you the baby is not moving as it used to, or is not moving at all, it could be sick or it may have died.

11.3  Listening for the baby’s heartbeat

The baby’s heartbeat gives information about the baby’s position inside the mother, and about the health of the baby. Listen to the heartbeat at each antenatal visit, starting at five months. Doctors and midwives often refer to the fetal heartbeat.

By the last two months of pregnancy, you can often hear the fetal heartbeat in a quiet room by putting your ear on the mother’s abdomen (Figure 11.10a). The heartbeat will be easier to hear if you have a stethoscope (Figure 11.10b) or a fetoscope (Figure 11.10c and d). If you don’t have a fetoscope, you can make a simple one from wood, clay, or a hollow tube of bamboo.

Different ways to listen to the fetal heartbeat
Figure 11.10  Listening to the fetal heartbeat with (a) your ear on the mother’s abdomen, or (b) with a stethoscope, or (c) and (d) with a fetoscope.

The fetal heartbeat is quiet and quick. It may sound like a watch ticking under a pillow, only faster. The fetal heartbeat is about twice as fast as a healthy adult heartbeat — usually 120 to 160 beats a minute. There is no need to count the heartbeats until the woman goes into labour. Hearing a clear fetal heartbeat during an antenatal visit just confirms that the baby is alive.

If you hear a ‘swishy’ sound (shee-oo, shee-oo, shee-oo), you are probably hearing the baby’s pulse in the umbilical cord. Cord sounds tell you how fast the baby’s heart is beating, but they do not help you find the baby’s position.

If the heartbeat sounds slow, you are probably hearing the mother’s pulse instead of the baby’s. Try listening to a different place on her abdomen.

11.3.1  Finding the baby’s position by listening to the heartbeat

Baby’s upper chest and upper back, where the heartbeat is loudest
Figure 11.11  The baby’s heartbeat is loudest in its upper chest or upper back, depending on which way the baby is facing.

Think about which way the baby seems to be lying. Then start listening for the heartbeat near the spot where you think the baby’s heart should be. You may need to listen in many places on the mother’s abdomen before you find the spot where the heartbeat is the most loud and clear (Figure 11.11).

Is the heartbeat loudest above or below the mother’s bellybutton? If you hear the heartbeat loudest below the mother’s bellybutton, the baby is probably head down (Figure 11.12a). If you hear the heartbeat loudest above the mother’s bellybutton, the baby may be in the breech position (Figure 11.12b).

(a) baby’s heartbeat below the mother’s bellybutton. (b) baby’s heartbeat is above the mother’s bellybutton
Figure 11.12  (a) If the fetal heartbeat is loudest below the mother’s bellybutton, the baby is probably in the vertex position. (b) If it is loudest above her bellybutton, the baby may be breech.

Sometimes when the baby is facing the mother’s front, the heartbeat is harder to find because the baby’s arms and legs get in the way. Listen near the mother’s sides, or directly in the middle of her abdomen, to hear the fetal heartbeat.

11.4  What to do if you find warning signs

11.4.1  Baby is breech

Breech babies are often born without any trouble, especially if the mother has had other children and her births were easy. But breech babies are more likely to get stuck, or have other serious problems.

Important! If the baby is breech at 36 weeks (8 months), refer the woman to a health centre. Don’t try to turn a breech baby (see Box 11.1).

Box 11.1 Don’t try to turn a breech baby!

Only a midwife, health officer or physician who has been trained to turn a breech baby should try to do so, and it should be done in a hospital. Trying to turn the baby by pushing on the uterus is very dangerous. Even a midwife, health officer or physician should not try to turn a baby if the mother’s water has broken, or if she has had vaginal bleeding, high blood pressure, surgery on her uterus, or caesarean surgery.

If the baby is not head down when labour starts, it is safer for the mother to give birth in a hospital. The midwife, health officer or physician can use forceps (pulling tools) if the baby gets stuck. Or they can do a caesarean surgery.

11.4.2  Baby is lying sideways

Sideways babies cannot fit through the mother’s pelvis to be born (Figure 11.13). If you try to deliver the baby without surgery, the mother’s uterus will rupture during labour, and she and the baby will die without medical care. If the baby turns head down at any time — even on the day the mother goes into labour — it is OK for her to give birth at home or at the Health Post.

Important!A baby lying sideways must be delivered by caesarean surgery in a hospital. Do not attempt to turn a sideways baby by hand. This is just as dangerous as trying to turn a breech baby, and should be done only by a doctor in a hospital.

Baby is lying transverse and must be born by caesarean surgery
Figure 11.13  If the baby is lying sideways (transverse lie) by eight months, you should make arrangements for a hospital birth by caesarean surgery.

11.4.3  Twins

Think back to what you learned in Study Session 10 about twin pregnancy.

  • What are the three signs of twin pregnancy?

  • The uterus grows faster or larger than normal. You can feel two heads or two bottoms when you feel the mother’s belly. You can hear two heartbeats (this is not easy, but it may be possible in the last few months).

  • What are the two ways to try to hear the heartbeats of twins?

  • Find the heartbeat of one baby. Ask a helper to listen for other places where the heartbeat is easy to hear, and both of you tap the rhythm of the heartbeats.

    Use a watch to help you count the two heartbeats.

11.5  After the antenatal check-up

A HEP doing an antenatal check-up

After you have finished checking the fetus and the mother, and following the instructions for any warning signs, find out if the woman has any more questions, or needs to talk about anything else. If she has any warning signs, carefully explain what the warning sign is, and what she must do to care for herself. If this is a return antenatal check-up, evaluate what you did for her at the previous check-up. Decide what else you may need to do for her. If she needs to be referred to a higher-level health facility, be sure she knows where and when to go.

11.6  Conclusion

In this session, you have learned how to examine the abdomen of a pregnant woman so that you can determine the position of the baby, its presenting part (head or bottom, or whether it is lying sideways), and how to check the wellbeing of the fetus by listening to the fetal heartbeat and asking the mother about fetal kick.

Summary of Study Session 11

In Study Session 11, you have learned that:

  1. It is reassuring to find one baby in the uterus and that the head of the fetus is down in the last month of pregnancy. Most babies are lying vertically by the seventh month with their head towards the cervix of the uterus. By the seventh or eighth month, the baby’s head has usually moved down in the mother’s pelvis. This is the safest position for a normal delivery.
  2. In any other situation, i.e. the baby is bottom down (breech), or lying sideways (transverse), refer the mother to the nearest health facility. Do not attempt to turn a breech or transverse baby.
  3. The position in the mother’s abdomen where she can feel the baby kicking can help you determine its position. Fetal kick is also a sign of fetal health. If the baby stops kicking it may be sick or have died, and the mother needs urgent referral.
  4. The baby’s heartbeat gives information about the baby’s position inside the mother, and whether it is alive. Hearing two heartbeats is a sign of twins. Listen to the heartbeat at each antenatal visit, starting at five months.
  5. By the last two months of pregnancy, you can often hear the baby’s heartbeat in a quiet room by putting your ear on the mother’s belly. The heartbeat will be easier to hear if you have a stethoscope or a fetoscope.
  6. The normal fetal heart rate is usually about 120 to 160 beats per minute.

Self-Assessment Questions (SAQs) for Study Session 11

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 11.1 (tests Learning Outcomes 11.1, 11.2 and 11.3)

Which of the following statements is false? In each case, say why it is incorrect.

A  Listening to the fetal heartbeat using a stethoscope is called auscultation.

B  When the fetal head is down and the bottom of the fetus is up in the fundus, it is called a vertical lie.

C  In a vertex presentation, the presenting part is the baby’s bottom.

D  The fetal heart rate is normally 120 to 160 beats a minute.

E  If the fetal heartbeat sounds loudest below the mother’s bellybutton, the fetal lie is probably breech.

Answer

A  True. Listening to the fetal heart beat using a stethoscope is called auscultation.

B  True. When the fetal head is down and the bottom of the fetus is up in the fundus, it is called a vertical lie.

C  False. In a vertex presentation, the presenting part is the baby’s head.

D  True. The fetal heart rate is normally 120 to 160 beats a minute.

E  False. In a breech presentation, the fetal heartbeat sounds loudest above the mother’s bellybutton.

Read the following case study carefully, and then answer SAQs 11.2 to 11.4.

Case Study 11.1  Bekelech

Bekelech came for her antenatal check-up at the eighth month of pregnancy. When you palpated her abdomen, you found a hard, round mass in the fundus of the uterus, and a soft, irregular, bulky mass towards the symphysis pubic. Bekelech told you that in the past week the baby’s kick had decreased, and when you listened to her abdomen with a fetoscope you could not hear the fetal heartbeat.

SAQ 11.2 (tests Learning Outcome 11.2)

  • a.Is the fetal lie in Bekelech’s case vertical or transverse? Explain how you reached your conclusion.

  • b.What is the presenting part in this case?

  • c.What do you call a fetus presenting in such a manner?

Answer
  • a.The hard, round mass in the fundus of the uterus is most likely to be the baby’s back, and the soft irregular shapes towards the pubic symphysis are its arms and legs. This is a vertical lie.

  • b.The bottom is the presenting part.

  • c.This is called a breech presentation.

SAQ 11.3 (tests Learning Outcome 11.3)

Where would you listen to the fetal heartbeat to confirm your diagnosis of how Bekelech’s baby is presenting, and why?

Answer

You would listen for the fetal heartbeat above Bekelech’s bellybutton because, if the baby is breech, its heartbeat will sound loudest there. (Look again at Figure 11.12 if you are not sure why this is so.)

SAQ 11.4 (tests Learning Outcomes 11.3 and 11.4)

What do you suspect is the condition of Bekelech’s baby, and what action should you take?

Answer

The baby may be sick, or even dead, because Bekelech says it isn’t kicking and you can’t hear a fetal heartbeat. You should refer her to a health facility immediately.