In first year I was pretty good at palpating the presenting part in the pelvis and how many 5ths of the fetal head were in the pelvis, this being done by abdominal palpation. Then all of a sudden I lost it, I lost all heads of babies. This made many a doctor and midwife laugh. Now I was certain these babies had heads and I was usually certain that I knew they were presenting cephalic (head down), but I couldn’t feel them. The reason I knew the heads were down was because I could feel the large bulky bottom at the top of the uterus, called the fundus. All through 2nd year I have struggled to regain my touch in this area, and it is only just returning to me.
The little things I have learned as a student are so important, most of these skills are learned by touch or observation. Through the later stages of pregnancy we measure the height of the fundus from the woman’s pubic bone and assess whether this correlates with her gestation (how many weeks pregnant she is). Midwives palpate the pregnant tummy in third trimester to determine what position the baby is in, and it can also be obvious if there is a possibility of too much or too little amniotic fluid surrounding the baby, among other things. You’ll notice in the picture below, that the fundal height can noticeably drop closer to the birth, approximately 40 weeks, due to the baby descending into the pelvis. The baby does not need to be engaged in the pelvis for labour to begin, especially for multiparous women (women having subsequent births).
Every abdominal palpation teaches you, the most interesting I have come across so far are:
Twins (I found very difficult)
Polyhydramnios (excessive amniotic fluid)
A transverse lie that eventually turned head down, was so excited when I discovered that, and it was very good news to the mother.
When I just felt shoulders, because the head was so low in the pelvis. I honestly couldn’t believe how a baby could sit that low and not be on its way out. It was definitely still in.
I have also learned that the height of the fundus can be altered due to fetal lie, a baby in a transverse lie can make the fundal height lower than if it was in a longitudinal lie. It makes sense.
I have used a doppler many times now to listen to the heart rate of the baby but have only used a pinard once. A pinard is what was used in the “olden days” haha, if you have seen Call the Midwife you will see them listening in to the baby through the tummy with a trumpet shaped looking thing. The skill needed for that is much more difficult to learn than using the doppler, I take my hats off to anyone skilled in it these days. I endeavor to learn, as I would love to be an efficient midwife without all the modern resources, you never know when you may be without it, or where you may be in the world. I was kindly shown how to measure fundal height without a tape measure, using my finger-breadths. Nobody else has ever shown me that, I went to do it one day at another facility and the midwife had no idea what I was doing without a tape measure!
Have any of you mothers ever noticed that a midwife knows your about to have a contraction before you even know? Often it’s because we have placed a hand on your tummy, usually near the fundus, and we can feel the muscle begin to harden under our hands as it builds into the next big wave, often before the mother notices it. I’ll ask, “Are you having another one?”, and I get, “Ummm, I don’t know… oh hang on… yep, here it comes!”.
This same fundus must also be palpated after birth to ensure that it is well contracted downwards, and central, to help the placenta separate, come away, and prevent excessive bleeding. Your beginning to think, damn, this fundus is very important!
Vaginal examinations (VE) are one of the most difficult skills to become confident at, it takes so much practice! You can get good at easier ones, but then a difficult one will come along, or the woman is uncomfortable so you don’t have alot of time to find what you need, so you end up with a very poor idea of what you felt. I find that I need time to think, feel, think and feel again, there is not much point in doing one if your not going to give it your best go at getting as much information as possible. It’s important that the woman is with you in agreement through it all and that you communicate.
These are just some of the foundational skills I have begun to learn, and although seemingly “basic” they are not easy to become accomplished at and you will always get a surprise that will turn everything you were so sure on upside down. I remember one VE and it changed everything that I imagined I was feeling. I remember having to draw it for another student because I had to explain it to someone else, so they too may have the light bulb moment! We both thought…. that’s not how they draw it in the textbook! In the textbook it always look so straight up and down, so you go in thinking that way. Below is typical picture of what the textbook makes it look like, and a rather simple drawing done by myself of what I felt. Please excuse the simplicity of it, I wasn’t about to draw for 2 hours to get all anatomical features in it.
As you can see, I would of felt a hard smooth surface, and I wasn’t expecting to feel a head this low, this wasn’t a woman in labour, I couldn’t find any edges of cervix, but it was almost impossible that this woman was fully dilated. In truth, The cervix was found behind the back of the head (what they call a ‘posterior cervix’), I almost couldn’t reach it, the head was just sitting so low that it was pushing down into vaginal wall and totally confused me! As labour nears or begins, the cervix becomes more central, or anterior, as they call it, not so posterior (behind, or to the back). In fact the anterior part of the cervix is almost always the last part to disappear, if a VE is done, the cervix will not be felt behind the baby’s head but a lip of cervix can be felt on the anterior side. The cervix does not dilate in a perfectly shaped circle! See below, it is not like the perfect circle on the left! I have been caught with two measurements and wondered which one to pick, the anterior to posterior one (front to back) or the transverse diameter.
I’m so thankful to the people who taught me some of the things that no one else explained or gave me the opportunity to do. The things I was taught with them are precious tools given to me by ones who have gone before but still go back, to take that extra 5 or 15 minutes teaching someone who was just like them not too long ago. And I’m thankful to the women who have let me into, sometimes just a moment, other times for months of their journey. I have so much to learn and not enough time to know it all, I never will! What I do learn, I want to share, so that others can be encouraged to learn and women to partake in their pregnancy and birth journey.
Disclaimer: This does not reflect any other persons or organizations opinions or learning materials, this is my own personal learning journey. This is not medical advice and readers should always look to evidence and professional guidance when making decisions about there health and well-being.