Abdominal palpation is an important aspect of your care during pregnancy. The regular antenatal appointments that you are invited to attend are very important because they enable your midwife to monitor your pregnancy. By seeing you at regular intervals, they are able to check that all is progressing as it should be and can monitor yours and your baby’s health and wellbeing. Where your midwife or doctor sees you regularly, any concerns can be identified much sooner and acted upon promptly.
Traditional approaches to monitoring your baby’s growth and development
Monitoring your baby’s growth is an important aspect of care in pregnancy. If the baby’s growth is poor, this should be identified as soon as possible because studies show us that delays in detection can result in poor outcomes, and, in the worst cases, baby deaths. The simplest method used by your midwife to determine fetal growth is to examine the baby by palpating (feeling) your abdomen with their hands and estimating the size of your womb compared with a ‘landmark’ i.e. your belly-button (navel).
Symphysis-fundal height (SFH) measurement
An alternative method often used to assess your baby’s growth is to measure the size of the womb with a tape measure. This is known as symphysis-fundal height (SFH) measurement and is taken from the mother’s pubic bone (symphysis pubis) to the uppermost border of her uterus/womb (fundus). The measurement is then applied to the gestation by a simple rule of thumb which is compared with normal growth.
SFH measurement is taken with a disposable tape measure and recorded in centimetres (cm). It is expected that the SFH measurement will be consistent with the number of weeks that you are pregnant, give or take 2 – 3cm. For example, if you are 32 weeks’ pregnant – your SFH measurement is expected to measure around 32cm, give or take the 2 – 3cm, as previously discussed. Should there be any concerns that your baby is growing poorly, or is larger than would normally be expected for that stage of pregnancy, then your midwife will refer you for an ultrasound scan (USS) and Obstetric Consultant review.
NB. Symphysis fundal height measurements are not performed on multiple pregnancies i.e. twins, triplets or more.
There are limited studies that have looked into which of these two methods is more accurate in detecting concerns with fetal growth. With such limited evidence available, it is still not known whether one method is more effective than the other; however, most UK maternity services continue to use SFH measurement as their preferred method. Best practice recommendations also include plotting these measurements on personalised/customised growth charts.
Ultrasound assessment can also be used to accurately detect fetal growth concerns; however, this is costly and not always available, and there are also concerns about its unnecessary use.
How is SFH measurement performed?
Research has found that by measuring your SFH in a consistent way; measurements will be a lot more accurate and there is less chance of variability between individual practitioners. This is particularly important, if you are seen in antenatal clinic by someone other than your usual midwife or doctor. SFH measurements are taken as follows:
- A disposable, non-stretch tape measure is placed longitudinally along the length of your abdomen with the start of the tape measure held at the symphysis pubis. This is done with the centimetre values hidden from your midwife’s view, which ensures a more objective measurement
- Your midwife will begin by feeling the uppermost border of the uterus and then measuring down from the fundus to the symphysis pubis. The Perinatal Institute recommends measurements are taken from the top of the fundus to the top of the symphysis pubis. Other literature however, describes measurement to be conducted from the symphysis pubis to the fundus
- The measurement should only be taken once, with your midwife undertaking follow-up measurements every two to three weeks
- The SFH measurement is recorded at each antenatal appointment from 24 weeks’ gestation and is documented in your hand-held maternity records. Best practice recommends that these are plotted on customised growth charts, but these are not used in all areas.
What happens if I measure small for my dates?
If your SFH measurement is found to be 2cm below your pregnancy’s gestation on two separate occasions, when measured at intervals two weeks apart – your midwife will recommend referral for an Obstetric Consultant review.
An appointment will be made for you to have an ultrasound scan (USS) to assess your baby’s size – this is called a ‘growth scan’. The growth scan will be booked in advance of your Antenatal Clinic appointment so that your Consultant Obstetrician has the scan results available when they see you. Sometimes, you may be seen by a senior Obstetric Registrar in the Day Assessment Unit instead. This will happen if your Consultant is unavailable and ensures there is no delay in your baby’s growth being checked.
What happens if I measure large for my dates?
If your SFH measurement is found to be 3cm above your gestational age, your midwife will recommend that you are booked in for a Glucose Tolerance Test (GTT). They will also arrange a growth scan prior to you being seen by an Obstetric Consultant at Antenatal Clinic. As before, sometimes, you may be seen by a senior Obstetric Registrar in the Day Assessment Unit instead. This will happen if your Consultant is unavailable and ensures there is no delay in your baby’s growth being checked.Your baby’s presentation and position in the womb
During the third trimester of your pregnancy i.e. from ‘week 27’ until the end of the pregnancy – your midwife may palpate (feel) your uterus.
This is particularly important at around 36 weeks’ gestation because it enables them to determine the position of your baby inside the womb. By doing so, they can identify whether your baby is presenting head-first (cephalic) or bottom-first (breech) and whether they are lying in an optimal position for birth. If your baby is thought to be in a position that isn’t good for vaginal birth, this needs to be confirmed by USS because it is likely to influence your birth plans. Your midwife and doctor will be able to talk through this in more detail, so you are able to understand the options available and can make an informed decision. For guidance on writing a birth plan see…
How is abdominal palpation performed?
Before beginning the examination of your abdomen, your midwife should provide an explanation of the procedure and ask for your consent. You will be invited to empty your bladder beforehand for comfort. You will then be asked to lie on a couch in a semi-recumbent position, with your arms by your side and advised to relax as much as possible, so that your uterus is relaxed. After washing their hands and ensuring they are warm, your midwife will expose your abdomen to an extent that enables her to perform a thorough examination. This examination includes the following:
- Your midwife will begin by looking at the size and shape of your abdomen. This can provide information on the possible lie and size of your baby. Skin changes in pregnancy such as ‘stretch marks’ and any previous caesarean section or other operation scars can also be observed. Sometimes, your midwife will also be able to see your baby moving inside the womb and will note the fetal movements seen
- ‘Lateral palpation’ is used to determine the baby’s position/lie inside the womb (i.e. longitudinal, oblique or transverse). This involves your midwife placing both of their hands on either side of your womb to identify your baby’s spine and limbs. During lateral palpation information regarding your baby’s size, the tone of your uterus and an estimation of the amount of amniotic fluid (waters surrounding baby) and fetal movements/activity can also be checked. Your midwife may also ask you whether you are feeling any fetal movements/kicks in a certain area, as this can also help to determine the baby’s position and presentation
- To determine whether your baby is a cephalic or breech presentation, your midwife will normally use a two-handed method; placing one hand on either side of the presenting part with their fingers directed inwards and downwards. This method tends to be more comfortable that when a one-handed approach is taken, with the midwife’s fingers facing your head. NB. Babies’ buttocks tend to be less defined, bulkier, softer and less ‘ballotable’ than a baby’s head
Whilst routine listening of your baby’s heart beat is not recommended, it may be undertaken at your request or to offer you reassurance. The baby’s heart beat can be checked using a Pinnards stethoscope or with a hand-held Sonicaid/Doppler. However, this will only provide reassurance that your baby is well at that specific point in time. Consequently, it is recommended that all pregnant women monitor their baby’s pattern of movements and level of activity in the womb. Where these decrease or change – you should contact your midwife/doctor immediately.
To conclude, abdominal examination is an important aspect of pregnancy care and is a means of monitoring pregnancies and detecting any concerns with fetal growth. However, it is also important that you feel comfortable with the examination and understand the procedure. We therefore advise that you discuss any queries or concerns with your midwife, so that you are involved in the decisions around your care in pregnancy and are able to make the right choices for you and your baby.
References and suggested further reading
Bais JMJ, Eskes M, Pel M et al (2004). Effectiveness of detection of intrauterine growth retardation by abdominal palpation as screening test in a low risk population: an observational study. European Journal of Obstetrics, Gynecology, and Reproductive Biology 116(2):164-169.
Baston H (2003). Monitoring fetal wellbeing during routine antenatal care. The Practising Midwife 6(4):29-33.
Blee D and Dietsch E (2012). Women’s Experience of the Abdominal Palpation in Pregnancy: A Glimpse into the Philosophical and Midwifery Literature. New Zealand College of Midwives Journal (46):21-25.
Buchmann EJ, Adam Y, Jeebodh J et al (2013). Clinical abdominal palpation for predicting oligohydramnios in suspected prolonged pregnancy. South African Journal of Obstetrics and Gynaecology 19(3):71-74.
Engstrom JL, McFarlin BL, Sampson MB (1993). Fundal height measurement. Part 4 – Accuracy of clinicians’ identification of the uterine fundus during pregnancy. Journal of nurse-midwifery 38(6):318-323.
Gardosi J and Francis A (1999). Controlled trial of fundal height measurement plotted on customised antenatal growth charts. British Journal of Obstetrics and Gynaecology 106(4):309-317.
Gibson J (2008). How to… perform an abdominal examination. Midwives 11(5):22.
Glover P (1996). Have we lost the art? Assessment and physical examination. Australian College of Midwives Incorporated Journal 9(4):5-8.
Henry M (2012). The accuracy of symphysis fundal height measurement. British Journal of Midwifery 20(9):640-644.
Holley S, Molina F, Fromberg E (2013). Tricks of the Trade. Palpation. Midwifery Today (108):7-7.
Jacobson AK (1993). Are we losing the art of midwifery? Journal of nurse-midwifery 38(3):168-169.
Maternal and Child Health Consortium. (2001) Confidential enquiry into stillbirths and deaths in infancy: eighth annual report. London: Maternal and Child Health Consortium.
McAllion D (2004). Fundal height measurement and low birth weight. British Journal of Midwifery 12(2):101-104.
Montagu S (2012). Observations, examinations and auscultation in different positions. Midwifery Matters (132):9-11.
NICE. (2008) Antenatal care: routine care for the healthy pregnant woman. London: RCOG.
Olsen K (1999). Midwife to midwife. ‘Now just pop up here, dear…’ revisiting the art of antenatal abdominal palpation. Practising Midwife 2(9):13-15.
Perinatal Institute (2007). Fetal growth fundal height measurements. Available at: www.pi.nhs.uk/growth/fhm.htm
Robert PJ, Ho JJ, Valliapan J et al (2015). Symphysial fundal height (SFH) measurement in pregnancy for detecting abnormal fetal growth. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD008136. DOI: 10.1002/14651858.CD008136.pub3.
Rosser J (2000). Cochrane made simple. Symphysis-fundal height measurement. Practising Midwife 3(1):10.
Stuart JM, Healy TJ, Sutton M, Swingler GR (1989). Symphysis-fundus measurements in screening for small-for-dates infants: a community based study in Gloucestershire. The Journal of the Royal College of General Practitioners 39(319):45-48.
Tully G (2010). Belly mapping: put positioning into parents’ hands. Midwifery Today (96):38-39.
Walker S and Sabrosa R (2014). Assessment of fetal presentation: Exploring a woman-centred approach. British Journal of Midwifery 22(4):240-244.