Hands off—Disappearance of the abdominal examination during pregnancy

A thorough and accurate history and physical examination of the pregnant woman has always been an integral part of obstetrical care. From the onset of modern medicine everywhere in the world, the importance of inspection, auscultation, percussion, and palpation was taught. Measurement and palpation of the pregnant abdomen have been crucial for determining fundal height, lie, and presentation of the fetus, as well as gestational age and estimated fetal weight. Every obstetrical visit included a measurement of the fundal height with a measuring tape (McDonald's rule). International standards for measurement of fundal height have been developed and validated.1-4 Fundal height measurements have been used to confirm gestational age and screen for discrepancies in fetal growth5-7 and amniotic fluid.8 With the exception of sonography, fundal height measurement correlated better than other screening methods for determining gestational age.9 The American College of Obstetricians and Gynecologists continues to recommend symphysis pubis to top of the fundus measurements be obtained at routine prenatal visits.10, 11 Examples of countries with similar published prenatal guidelines include United Kingdom, New Zealand, Canada, Ireland, and France.12 All of medicine, including obstetrics, has changed over the years, primarily because of advancements in technology. It is quite amazing that within the course of the last 30 years, in Israel the pregnant woman's abdomen is no longer routinely palpated and the fundal height is no longer measured. Leopold maneuvers for lie, presentation, position, and clinical estimated fetal weight are in fact rarely used, and these skills have been forgotten. Although still appearing in textbooks, students and residents in Israel are no longer exposed to measurement of fundal height or to perform Leopold's maneuvers chiefly because their mentors have themselves stopped the practice. The accuracy or necessity of this clinical approach is now questioned by the younger generation of obstetricians who may have no idea how and why to measure fundal height. In addition, in the #MeToo era, physicians have become hesitant to touch (palpate) a patient's abdomen especially as patients are becoming accustomed not to having this done. Patients themselves now question what is going on when approached by an obstetrician with a measuring tape and may never come in contact with one. Of course, we cannot be completely certain that there are not a few stragglers, like ourselves, who continue to carry a measuring tape in their laboratory coats. This hands-off trend is not unique to Israel, but seems to be occurring in some other high resource countries as well, such as some Western European countries. On the other hand, low resource countries and areas still rely on fundal height and abdominal examination. The main reason for the abandonment of the measuring tape and palpation coincides with advancements in modern technology and the ultrasound machine. At each visit in areas of an abundance of resources, instead of using a measuring tape, the physician reaches for the readily available ultrasound transducer. Most often, fetal biometry, fetal heart activity, and a subjective assessment of amniotic fluid are quickly documented at every encounter. This corresponds to a routine of at least 10 ultrasound examinations for low-risk women throughout their pregnancy, and some high-risk women may have more than 20 such examinations. Women have come to expect an answer to their question "how much does my baby weigh today?"; "does everything look okay today?"; or “why aren't you scanning my baby today?” They are also looking for the "wow" factor, to be able to see their fetus, to get a picture, and post it online even before the visit is completed. A picture of a measuring tape is not nearly as compelling. There are several factors that have facilitated this change. First, there are no universally accepted and published guidelines in many countries for prenatal care especially in regard to palpation and fundal height measurement. Second, in Israel and other high resource countries, ultrasound machines have become readily available in every outpatient clinic. Third, in many countries there is no extra patient charge for these limited office sonograms and in some countries there is actually a financial incentive for the physician to perform these scans. This is in contrast to the restricted use of ultrasound in the United States where medical insurance might only pay for a dating scan, a second-trimester anomaly scan, and/or possibly a third-trimester growth scan in low-risk women. In many countries, in obstetric hospitals and clinics, an ultrasound machine usually sits alongside the examination table. It is neither rolled in and out as needed nor is it even in a separate room. The woman is not asked to move to a separate room for a "special" examination. The machine is there, on display, and easily accessible. The examination itself is easy to perform and for basic needs takes no more than a minute or two. The physician is pleased, since the patient is pleased. The expectant mother gets to see parts of the baby, maybe some movement, maybe a facial profile, certainly the heart activity which can be heard as well if Doppler is applied. Finally, the physician cannot perform these brief ultrasound examinations only on select patients since the ethical principle of justice requires equal treatment for all pregnant women regardless of their risk status. Pregnant women now expect to have this same feeling of satisfaction at each visit and will take notice if ultrasound is not done. This symbiosis, in an exponential fashion, has led to replacement of the measuring tape in the examination room. Fundal height is no longer recorded, and there is no need for “touching” the abdomen. Has this been a change for the good or is it a false sense of security when the physician says everything looks well on these brief ultrasound examinations? In the past when an obstetrician tried to reassure a patient, everyone understood the limitations of these reassurances. Today, false reassurance may have dire medical-legal consequences for the health care provided. The physician has adapted well. Patient satisfaction is maintained at minimal additional effort or time investment. However, with no training and experience in fundal height measurement, the obstetrician has forgotten that fundal height and clinical examination, when done meticulously, are very good screening tools for abnormalities of fetal growth in most women. One may argue that these frequent ultrasound examinations may detect more abnormalities in amniotic fluid volume. This might be true, but would not a patient with oligo- or polyhydramnios have an abnormal fundal height triggering an ultrasound examination? Of course, the real question remains: Does the routine use of ultrasound improve pregnancy outcomes? In one study comparing clinical weight estimation to sonographic weight estimation, there was no difference in mean error between the two modalities.13 In fact, in the weight range 2500-4000 g, clinical estimation was found to more accurate.14 It is unknown whether the routine use of ultrasound results in less morbidity and mortality to the fetus/newborn. It is not known for sure whether this practice has had an influence on interventions, such as induction of labor, cesarean delivery, or future litigation. Whatever the case, the measuring tape and abdominal examination are disappearing from obstetrical practice in many places, probably never to return unless there will be national guidelines and a unified attempt and cooperation by practitioners and their patients to limit the use of ultrasound. This same fate might be inevitable in other high-technological societies where low-cost and pocket ultrasound machines are becoming readily available. Other instruments and procedures used in obstetrics have had similar fates throughout the years for various reasons, such as the pudendal needle, Kielland and Piper forceps, and x-ray pelvimetry. Transvaginal measurement of cervical length is usurping digital examination of the cervix, when in fact neither test offers a significant advantage in predicting preterm birth.15 Whatever the case, changing technology leads to changes in practice. Until high-quality research is available, whether these changes lead to better perinatal outcomes is up to each of us to decide.

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