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Abdominal Examination in Pregnancy: All Three Trimesters
A complete, trimester-by-trimester guide to obstetric abdominal examination with clinical landmarks, techniques, and images.
🔷 Before You Begin: General Setup
Patient Positioning
| Gestational Age | Position | Reason |
|---|---|---|
| < 28 weeks (1st & 2nd trimester) | Supine, head raised 15-30° | Uterus small enough - no vascular compression |
| > 28 weeks (3rd trimester) | Left lateral tilt (small pillow under right hip) | Prevents aortocaval (IVC) compression causing supine hypotensive syndrome |
Always ask the patient to void before examination - a full bladder obscures fetal contour and causes discomfort.
Systematic Order of Examination
- Inspection - skin changes, shape, size
- Palpation - uterine size, fundal height, fetal parts
- Auscultation - fetal heart rate
📍 Fundal Height: The Most Important Landmark
Textbook Diagram - Fundal Growth at Various Weeks
Fig. A - Fundal growth landmarks at 12, 16, 20, 30, and 40 weeks (Textbook of Family Medicine, 9e)
Detailed Fundal Height Reference Diagram
Fig. B - Fundal height contours from 12 weeks to term, with regression at 40 weeks as the presenting part descends
Fundal Height Landmarks at a Glance
| Weeks | Fundal Position | Key Landmark |
|---|---|---|
| 8-10 weeks | Not yet palpable abdominally | Still in pelvis |
| 12 weeks | Just above pubic symphysis | Pubic bone edge |
| 14-16 weeks | Midway between pubis and umbilicus | Between landmarks |
| 20-22 weeks | At the level of the umbilicus | Umbilicus (belly button) |
| 24 weeks | ~4 cm above umbilicus | — |
| 28 weeks | ~8 cm above umbilicus | — |
| 32 weeks | Midway between umbilicus and xiphoid | — |
| 36-38 weeks | At or near xiphoid/sternum | Xiphoid process |
| 40 weeks (term) | Drops slightly below 36-38 wk level | Lightening - head engages |
McDonald's Rule: From 20-32 weeks, fundal height in cm ≈ gestational age in weeks (±2 cm). E.g., at 26 weeks → expect ~24-28 cm.
🟢 FIRST TRIMESTER (Weeks 1-13)
What to Expect
The uterus is a pelvic organ - it cannot be palpated abdominally before 12 weeks.
Inspection
| Feature | What You See | Significance |
|---|---|---|
| Abdominal shape | Flat or minimally distended | Normal - uterus still pelvic |
| Linea nigra | May begin to appear (dark midline line from pubis to umbilicus) | Caused by placental melanocyte-stimulating hormones - normal |
| Striae gravidarum | May begin to form | Stretch marks from dermal tearing - striae rubra (red/pink) appear first |
Palpation
- Uterus: Not palpable abdominally until ~12 weeks
- At 12 weeks: fundus is palpable just at the superior edge of the pubic symphysis
- Gently palpate the lower abdomen just above the pubic bone to feel the uterine dome
- Assess for tenderness (ectopic, miscarriage, fibroid degeneration)
Auscultation
- Fetal heart tones detectable by Doppler from ~10-12 weeks (not by Pinard stethoscope yet)
- Normal FHR: 110-160 bpm
Key Clinical Points - 1st Trimester
- Bimanual pelvic examination is more informative than abdominal exam at this stage
- Hegar's sign: softening of uterine isthmus on bimanual (8-10 wks)
- Goodell's sign: softening of cervix
- Any abdominal pain + positive pregnancy test → rule out ectopic pregnancy
🟡 SECOND TRIMESTER (Weeks 14-27)
What to Expect
The uterus rises out of the pelvis, becoming an abdominal organ. Fundal height measurement becomes clinically useful from 20 weeks onward.
Inspection
| Feature | What You See | Notes |
|---|---|---|
| Abdominal distension | Visible uterine swelling, rounded | Progressive, symmetric |
| Linea nigra | Prominent dark line, pubis to umbilicus (sometimes to xiphoid) | Normal - fades postpartum |
| Striae gravidarum | Pink/red stretch marks (striae rubra) on flanks, lower abdomen | Normal |
| Umbilicus | May flatten or begin to protrude | As uterus expands |
| Fetal movements | Visible skin movement ("quickening") from ~20 weeks | Seen in thin patients |
Palpation - Fundal Height
- From 20 weeks: measure with a tape measure from the superior border of the pubic symphysis to the top of the uterine fundus
- The distance in cm should equal the gestational age in weeks (±2 cm)
- Feel for uterine contour: smooth, firm, non-tender
Organ displacement to be aware of:
- The appendix is pushed superiorly toward the RUQ as the uterus grows - so appendicitis pain may NOT be in the typical right lower quadrant
Palpation - Fetal Parts
- Fetal parts can be felt from ~24-26 weeks
- The fetus is still very mobile - position changes frequently
- The fundal grip identifies which pole is in the fundus
Auscultation
- Pinard stethoscope (fetal stethoscope): audible from ~20-24 weeks
- Doppler: audible from 12 weeks
- Location of heart tones: varies with position - best heard through the fetal back
Key Clinical Points - 2nd Trimester
- Fundal height larger than expected: multiple gestation, polyhydramnios, LGA fetus, uterine fibroids
- Fundal height smaller than expected: oligohydramnios, fetal growth restriction (FGR), inaccurate dates, fetal demise
- Braxton Hicks contractions may be felt - painless, irregular
- Organise referral if fundal height deviates >2 cm from expected
🔴 THIRD TRIMESTER (Weeks 28-40)
What to Expect
This is the most detailed phase of abdominal examination. Leopold's Maneuvers are performed from 30 weeks to determine fetal position and presentation.
Inspection
- Large, globular abdomen
- Fetal movements (kicks, rolls) visible through the abdominal wall
- Linea nigra prominent
- Umbilicus may be everted
- Lightening/engagement: at ~36-38 weeks in nulliparas, the fundus drops and the lower abdomen appears more prominent as the fetal head descends into the pelvis
🔬 LEOPOLD'S MANEUVERS (3rd Trimester - from 30 weeks)
Textbook Diagram - All 4 Maneuvers
Fig. C - A: 1st maneuver (fundal grip), B: 2nd maneuver (lateral/back location), C: 3rd maneuver (presenting part), D: 4th maneuver (cephalic prominence) - Textbook of Family Medicine 9e
Clinical Reference Chart - Leopold Maneuvers
Step-by-Step Guide
MANEUVER 1 - Fundal Grip (What is in the fundus?)
Examiner faces maternal head
How: Place both hands on either side of the uterine fundus, fingers close together near the xiphoid. Gently palpate with fingertips.
| Finding | Interpretation |
|---|---|
| Hard, round, smooth, ballottable | Fetal head → breech presentation |
| Soft, irregular, less distinct, moves with trunk | Fetal buttocks → vertex (head down) presentation |
| No distinct fetal pole | Possible transverse lie |
Also used to estimate gestational age by fundal height (McDonald's rule).
MANEUVER 2 - Lateral/Umbilical Grip (Where is the fetal back?)
Examiner faces maternal head
How: Slide hands down from fundus to the lateral walls of the uterus. Stabilize one side while palpating the opposite side with the other hand. Alternate sides.
| Finding | Interpretation |
|---|---|
| Smooth, hard, continuous, convex surface | Fetal back |
| Irregular, knobby, multiple small parts | Fetal limbs / small parts |
The back and limbs are on opposite sides. Fetal heart tones are best auscultated over the fetal back.
MANEUVER 3 - Pawlik's Grip / Lower Pole Grip (What is the presenting part?)
Examiner faces maternal head
How: Cup the lower abdomen just above the pubic symphysis with one hand (or both hands) and gently grasp the presenting part. Move it gently from side to side.
| Finding | Interpretation |
|---|---|
| Round, hard, smooth, can be ballotted (moves independently) | Head (vertex) - not yet engaged |
| Irregular, soft, not ballottable | Breech |
| No presenting part palpable | Head may be deeply engaged |
MANEUVER 4 - Pelvic Grip (Is the head flexed? Degree of engagement?)
Examiner TURNS 180° to face maternal feet
How: Place both hands on either side of the lower uterus, fingers pointing toward the pelvis. Press downward and inward.
| Finding | Interpretation |
|---|---|
| One hand meets resistance first (cephalic prominence on one side) | Head is flexed (well-flexed = normal vertex) if prominence is on same side as small parts (limbs) |
| Cephalic prominence on back side | Head is extended (face/brow presentation) |
| Both hands meet equal resistance | Head is military attitude (neither flexed nor extended) |
| Hands converge into pelvis | Head is deeply engaged |
Fetal Positions and Heart Tone Locations
| Fetal Position | Best FHR Auscultation Location |
|---|---|
| Left Occiput Anterior (LOA) - most common | Left lower quadrant, below umbilicus |
| Right Occiput Anterior (ROA) | Right lower quadrant, below umbilicus |
| Left Occiput Posterior (LOP) | Left lateral, near flank |
| Breech | Above umbilicus (periumbilical) |
| Transverse lie | Level of umbilicus, on side of fetal back |
📋 Symphysis-Fundal Height (SFH) Measurement - Technique
- Patient supine (left tilt if >28 wks)
- Locate the superior border of the pubic symphysis with one end of the tape
- Run the tape over the uterine contour to the top of the fundus (not the skin fold)
- Read the measurement in centimeters
- Plot on a customized growth chart
Normal: SFH (cm) = gestational age in weeks ± 2 cm
| SFH Result | Consider |
|---|---|
| > expected by >2-4 cm | Polyhydramnios, multiple gestation, LGA, wrong dates, fibroids |
| < expected by >2-4 cm | FGR, oligohydramnios, wrong dates, fetal demise, transverse lie |
⚠️ Contraindications & Limitations
Conditions reducing Leopold accuracy:
- Maternal obesity (BMI >35)
- Polyhydramnios (excess fluid)
- Anterior placenta praevia
- Multiple gestation
- Engaged head (makes palpation difficult)
- Patient discomfort / non-cooperation
Contraindications to vigorous palpation:
- Placenta praevia (confirmed)
- Active preterm labor
- Premature rupture of membranes (use caution)
Ultrasound is the gold standard for confirming fetal presentation when any malpresentation is suspected, and is recommended when Leopold findings are uncertain.
🩺 Summary Table: Trimester-by-Trimester Abdominal Exam
| Feature | 1st Trimester (0-13 wks) | 2nd Trimester (14-27 wks) | 3rd Trimester (28-40 wks) |
|---|---|---|---|
| Uterus palpable | From 12 wks (pubic level) | Yes - rising abdominally | Yes - large |
| Fundal height | Not measurable | From 20 wks (SFH in cm ≈ wks) | Continuous monitoring |
| Fetal parts felt | No | From ~24 wks | Yes - clear |
| Leopold maneuvers | Not applicable | Limited value | Full 4 maneuvers from 30 wks |
| Fetal heart - Doppler | From 10-12 wks | Yes | Yes |
| Fetal heart - Pinard | No | From ~20-24 wks | Yes |
| Position/presentation | N/A | Variable | Document from 30-36 wks |
| Key concern if abnormal | Ectopic, miscarriage | FGR, polyhydramnios | Malpresentation, engagement |
| Patient position | Supine 15-30° | Supine 15-30° | Left lateral tilt |
📚 Sources
- Textbook of Family Medicine, 9e (Rakel) - Figs. 20-2 and 20-3 (fundal growth and Leopold maneuvers diagrams)
- Leopold Maneuvers - StatPearls/NIH - comprehensive clinical technique reference
- Medmastery - Abdominal Exam in Pregnancy - trimester-by-trimester positioning guide
- Peninsula Health Clinical Practice Guideline - Abdominal Palpation in Pregnancy - SFH measurement protocols
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