ANTENATAL ASSESSMENT

OBJECTIVES

After going through this practical unit, you should be able to:

· give comprehensive antenatal care;

· explain the procedure of antenatal registration and collect necessary information;
· perform antenatal examination;
· identify normal and abnormal changes during antenatal examination;
· list the articles required for antenatal examination;
· conduct physical and abdominal examination;
· differentiate normal and abnormal findings during obstetrical examination;
· identify women at risk during antenatal examination; and
· assess health education needs of women and conduct need based health education.

INTRODUCTION
In India one woman dies every five minutes from pregnancy related causes. Most of these
deaths can be prevented or can be avoided if preventive measures are taken and adequate
care is available. Maternal death is a tragedy for the individual woman, family and
community. In developed countries the maternal mortality is 27 maternal deaths per 1 lakh
live births and in developing countries the ratio is nearly 20 times i.e. 480 maternal deaths per
lakh live births. To reduce the maternal mortality antenatal care can play a very important
role. In this practical unit we will tell you about antenatal examination and how you will
perform antenatal examination.
ANTENATAL EXAMINATION AND CARE
It becomes a major responsibility of nurse to provide excellent antenatal care to the mother
from the day mother regards to the health worker in community hospital.
Definition and Meaning
Antenatal care is defined as the systematic examination and advices given to the pregnant
women at regular and periodic intervals based on the individual needs starting from the
beginning of pregnancy till delivery. Antenatal examination is carried out whenever a woman
visits the clinic for antenatal check up.

Aims of Antenatal Care

i) Ensure normal pregnancy with healthy baby and mother.

ii) Monitor the progress of pregnancy by conducting regular examination
iii) Prepare and encourage the pregnant woman and her family to have a healthy
psychological adjustment to child bearing.
iv) Prevent and detect any complication at the earliest and provide care as required.

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v) Provide need based health education an all aspects of antenatal care and importance of
planned parenthood.
vi) Prepare the mother for confinement and postnatal care and child rearing.

Components of Antenantal Care

 Setting up antenatal clinic with all essential facilities.

 Registration
 History taking
 Investigations
 Antenatal examination
 Abdominal examination (obstetric examination)
 Vaginal examination
 Health education on various aspects of (family centred maternity care.
 Let us discuss how you can organize care for antenatal women.
 A woman should be encouraged to register for antenatal check-up when she is
confirmed of being pregnant, as soon as she misses her normal period.

SETTING UP ANTENATAL CLINIC

Articles Required for Antenatal Examination

 Examination Table-if in the clinic or on the bed at home

 Draping sheet
 Screen or curtain
 Urine testing articles and bottle for specimen
 Temperature tray
 Weighing scale
 BP apparatus
 Kidney tray
 Paper bag
 Torch
 Stethoscope
 Tape measure
 The place where you would provide antenatal care should be clean, well ventilated and
properly lighted.
History Taking

Registration: The women should be registered after confirming that she is pregnent
(possibly). Afterwards midwife will carryout the following:
1) Identification data — age, marital status, education, occupation, family composition,
housing etc. The data includes complete soicio-cultural and economic background of the
client and her family.
2) Reason(s) for visiting the clinic.
3) History taking:
a) Surgical history:
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  history of any operation,
 injury or accidents,history of blood transfusion,
etc.
b) Family history:
 both maternal and paternal history of breech delivery,
 twin delivery,
 hypertension,
 heart disease,
 diabetes, and
 congenital malformation
c) Personal history — health habits like smoking, drinking, drugs or any other past
medical history

 History of heart disease any disease since childhood like,

 rheumatic fever,
 pulmonary disease,
 convulsions,
 allergies, · renal disease,
 diabetes, etc.
d) Menstrual history:
 age at first menstrual period,
 last menstrual period date,
 duration of each period,
 any complaints like dysmenorrhoea, ·
 amount of blood flow
e) Obstetrical history—
 gravid para
 past obstetrical history nature of pregnancy (preterm full term)
labour
 puerperium — (normal/afebrile)
 new born sex, healthy
 age at first pregnancy
 present pregnancy — any specific health problems
Investigations
 Urine — Albumin and sugar every visit
 Blood — Hb testing on every visit, once a month to exclude anaemia.
Normal Hb 10-12 gm %
 Blood group
 VDRL for syphilis done on the first visit
 HIV test for high risk groups
 Ultrasound- To be done if indicated (If sending for an ultrasound make sure bladder is
full)
 TORCH Test – To rule out the following infections (in selected cases)

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 T : Toxoplasmosis
O : Other Viral infections
R : Rubella
C : Cytomegalovirus
H : Herpesvirus

Physical Examination

This includes complete systematic examination of each system and assessing its function.
Physical measurements include:
· Height Make the woman stand against the wall and measure
the height.
Average height of an Indian woman is 145-150 cms.
Height indicates the pelvic size.
· Weight Weight checking should be done at each visit.
Obesity can lead to risk of gestational diabetes.
Average weight of an Indian woman in the age group
of 25-30 yrs is 60 kgs.
 During pregnancy the weight increase in the:
 First trimester — 1 kg.
 Second trimester and Third trimester — 5 kg. (2 kg a month) Total weight gain during
pregnancy is approximately 11 kgs.
 The total weight gain during pregnancy indicates the birth weight of the child
 A higher than normal increase in weight indicates early manifestation of toxemia.
 Stationary weight for some period of pregnancy suggests intrauterine growth
retardation or intrauterine death.
 Poor weight gain also indicates foetal abnormality.
 Blood pressure Blood pressure should be recorded during each visit. Any reading
above 140/90 should be reported.
 Vital signsTemperature, pulse, respiration to be recorded in each visit

Head and Toe Examination

Complete systematic examination from head to toe.

1.Hair and Scalp — healthy or infection
2.Eyes
—Observe the color of the conjunctiva – yellow, pink or normal.
—Sclera – normal, yellow tinge suggest anaemia
—Infection, discharge
i) Mouth
— Hygiene

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— Gums and teeth — healthy, cavities, infection iv) Ear, Nose and
Throat -— Healthy, enlargement or infection.

v) Breast changes—Normal changes during pregnancy

· 3-4 wks — Pricking and tingling sensation
· 6 wks — Enlarged, tense, painful
· 8 wks — Bluish surface, veins visible
· 8-12 wks— Montgomery glands become prominent
on the areola
· 16 wks— Colostrum can be expressed
vi) Abdomen — Palpate for liver or spleen enlargement or any other abnormality

vii) Skin
vii) Observe for any scar or infection
viii)Extremities —Upper: Check hands, color of nails-pink or pale, shape of nails Lower : Any
pain, tenderness, varicose veins, presence of oedema
ix) Back and Spine:
— Observe the back and spine for any deformity

PROCEDURE FOR EXAMINATION

Physical Examination
 Collect all required articles
 Keep room ready
 adequate light
 Privacy
 Warm or as per season
 Prepare the mother explain the procedure
 ensure that the bladder is empty
 give a comfortable and relaxed position
 Stand on the right side of the woman or the examination table
 Collect relevant history which includes identification data, socio-economic data,
cultural, medical, surgical, family and personal history
 Collect information about previous pregnancies and the present one and record in the
performa or the card
 Drape the mother and provide enough privacy by curtain or screen
 Do a thorough physical examination from head to toe and record the findings and also
record on
 Bowel and bladder habits
 Any complaints related to pregnancy or minor ailments
 Explain and assist in routine investigation like urine, stool or blood.

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Abdominal Examination
A thorough abdominal examination of pregnant woman helps to determine the lie,
presentation, and position of the foetus.
General Instructions to be kept in mind during abdominal examination:

 Make your hands warm before examining

 Explain the procedure
 Touch the abdomen lightly to reduce reflexive reaction
 Explain the woman to lie down in dorsal position with thighs slightly flexed with upper
part of the body supported by a small pillow and expose the abdomen fully
· Do systematic examination-inspection followed by palpation and
finally auscultation
· Keep the fingers together and use the palms surface of the fingers
· Use smoothly applied pressure to palpate the returns
· Palpation should be continuous i.e. do not lift your hand till the
whole palpation is done. Follow the four sequential steps of
palpation (Leopolds manouever). This will help you to gain and
improve accuracy of your findings manouever.
· Do not press hard with the fingers as it is painful.
1) Inspection

Which means observation of size, shape, contour, skin changes, foetal movements. The
presence of scar, rashes, lesions, diluted veins, pulsations, presence of linea nigra can also
be observed. Foetal movements can be observed as early as 18 to 20 wks. in primigravida
and 16 wks in multigravida. Mother may be asked to report about foetal movements and
report if excessive or lack of movement.

2) Palpation
Abdominal palpation should be done between 16-20 wks of gestation onwards, when foetal
parts are palpable. Period of gestation can be assessed by noting the actual growth of the
foetus in weeks by assessing the height of the fundus in weeks and by measuring the
abdominal girth. These findings can be compared with actual period of pregnancy or
amenorrhoea to estimate if it is normal.

a) Fundal Height: can be measured by measuring the distance between the symphysis pubis
and the fundal curve using tape measure or fingerbreadth. This measurement provides
information about the progressive growth of pregnancy. Umbilicus is usually taken as a
landmark for measuring or assessing fundal height. You can place the uterus border of
your left hand over the abdomen just below the xiphisternum. Pressing gently move the
hand down the abdomen until the curved uppermost border part of the fundus is felt by the
examining hand.
 McDonald’s Measurement is done by using the tape measure. This measures the
distance between the upper border of symphysis pubis to the uppermost curved level
of the fundus in cms or in inches in the midline passing over the umbilicus. It is
applicable beyond 24 wks of pregnancy. Measured fundal height divided by 3.5 gives
the duration of pregnancy in lunar months.
 Using 3 finger breadth — which is approximately equivalent to 5 cms or 2 inches or 4
wks of lunar months. In this also 3 fingers from upper border of the symphysis pubis till
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 the uppermost curve of the fundus. The growth chart of the foetus as per finger
measurement is given below.

Measurement of fundal height

 12 weeks — Uterus is just about the symphysis pubis
 18 weeks — Uterus half way between the symphysis pubis and umbilicus
 20 weeks — above the half way but 2.5 cms below the umbilicus
 24 weeks — fundus will be present at the upper margin of the umbilicus about 20 cms
from the symphysis pubis or 3 finger breadth above 20 weeks.
 28 weeks — fundus is 1/3rd from the umbilicus to the xiphisternum or 30 cms from the
symphysis pubis approximately.
 32 weeks — 2/3rd distance from the umbilicus and xiphisternum, 6 finger above the
umbilicus
 36 weeks — 3/3rd distance, which means at the level of xiphisternum approximately 35
cms or 13-14 inches
 40 weeks — mostly lightening takes place and uterus descends down to the level of 32
wks.
 Sometimes fundal height does not correspond with period of gestation and the reasons
could be:
i) Multiple pregnancy ii) Polyhydramnios iii)
Foetal macrosomias iv) Big baby

v)Wrong dates
If the fundal height is less than the period of gestation then it could be due to:

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i) Abnormal foetal presentation ii) Growth retarded
foetus iii) Congenital malformations iv)
Oligohydramnios

v) IUD (Intrauterine Death) vi) Wrong dates

Observe for lightening if it has occurred. Observe for presenting part if it has settled in the
pelvis. At this time the fundal height decreases.

b) Assess Abdominal Girth: Abdominal circumference is measured with help of tape

measure. Normal increase of 1 inch or 2.5 cms. per week after 30 weeks. Measurement in
inches is same as the wks of gestation after 32 wks in an average built woman. For
example, the abdominal girth in a 32 weeks pregnant mother may be 32 or 31 inches.

c) Grips Used in Abdominal Palpation: Abdominal palpationis done using 5 types of grips
which are:

1) Fundal Grip

2) Lateral Grip

3) Pelvic Grip — Deep Pelvic palpation

4) Pelvic Grip — Pawlick Manoeuver

5) Combined Grip
First Palpation Using Fundal Grip
You should stand facing patient’s head, use the tips of the fingers of both hands to palpate
the uterine fundus.
— When foetal head is in the fundus, it will be felt as a smooth hard, globular, mobile and
ballotable mass.
— When breech will be in the fundus, it will be felt as soft irregular, round and less mobile
mass.
This manoeuver will enable to assess the lie of the foetus which is the relationship between
the long axis of the foetus and the long axis of the uterus. The lie is mostly longitudinal or
transverse but occasionally it may be oblique. This palpation or manoeuver also helps in
identifying the part of the foetus which lies over the inlet of the pelvis. The commonest
presentation are mostly vertex (head)

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 Fundal palpation
Second Manoeuver — Lateral Palpation

For performing the lateral grip also you keep facing the patient’s head and place your hands
on either side of the abdomen. Steady the uterus with your hand on one side and palpate the
opposite side to determine the location of the foetal back.
— The back area will feel firm
— Small baby parts like hands, arms and legs will be felt like irregular mass and may be
actively or passively mobile.
This grip helps to identify the relationship of the foetal body to the front or back and sides of
the maternal pelvis. The possible positions are anterior, posterior, etc.

(a) (b)
Lateral palpation

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Third Manoeuver — Deep Pelvic Palpation
During this grip you will face the patient’s feet. Gently move your fingers down the sides of
the abdomen towards the pelvis until the fingers of one hand encounter the bony prominence.
— If the prominence is on the opposite side of the back, it is the baby’s brow and the head is
flexed.
— If the head is extended then the cephalic prominence will be located on the same side as
the back and will be the occiput.
— In this when there is cephalic prominence and the foetal head is felt over the brim of the
pelvis it is Flexed Attitude.
— When the forehead forms the cephalic prominence and the head is extended it is called
Extension Attitude.

(a) Pelvic palpation (b) Deep pelvic Grip

Fourth Manoeuver — Pawlick Grip
Place the tips of the first three fingers of each hand on either side of the abdomen just above
the symphysis pubis and ask the patient to take deep breath and exhale. As she exhales,
sink your fingers down slowly and deeply around the presenting part. This grip will help you
to identify the presenting part. This is the part that first contacts the finger in the vaginal
examination most commonly it is the head or the breech.

Combined Grip
In this grip the fundal grip alternate with the Pawlick grip. It is done in cases where one is still
doubtful about the above palpation. After abdominal examination vaginal examination may be
done to assess the pelvis in later months.

3)Auscultation
Auscultation is done to monitor the foetal heart sounds. The rate and rythm of the foetal heart
beat gives an indication of its general length. This may be possible after 18 to 20 weeks.
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Normal foetal heart rate is 120-140 beats per minute. If a doppler ultrasound device is used,
it can be detected as easy as 10 weeks of gestation. The point of clearest heart tones for
various foetal positions is shown. Heart tones are best heard through the fetus’s back.
Loudness of the foetal heart tones depends on the closeness of the foetal back to mother’s
abdomen.
When you are searching for heart tones, the normal rapid beats confirms that the examiner is
learning the foetal heart beat rather than that of the mother. If the foetal heart rate is less than
100/min or more than 160/min with the uterus at rest it may indicate foetal distress. Regularity
of the beat is a normal finding; irregularity of the beat is abnormal finding.

Fig. 2.5: Pawlick grip

Foetal heart auscultation using foetoscope

Other sounds heard in the abdomen are tunic souffle, counted by the rushing of the blood
through the umbilical arteries, and uterine souffle, caused by the gush of blood passing
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 through the uterine blood vessels. Uterine souffle, is synchronous with FHR while uterine
souffle 4th motional rules.
Failure to hear foetal heart rates may be because to:
—Defector fetoscope or noising environment, anxiety of the examiner early
—Fetal death
—Obesity, hydrogenous, low placental souffle, posterior position of foetus
After palpation and auscultation findings, of the examination is recorded which includes:
1) Lie — Longitudinal/Oblique/Transverse
2) Period of Gestation in Weeks
3) Presentation — Cephalic/Breech
4) Attitude — Flexed/Extended
5) Position — Anterior/Posterior
6) Foetal Heart Rate — 120/140/Above or Below
After recording the findings explain the mother regarding various aspects of antenatal care.

ANTENATAL ADVICES
Need based health education should be given related to:

 Diet in pregnancy — Adequate, balanced, nutritious, easily digestible, rich in protein,

minerals and vitamins. Be realistic and reasonable in the advice given keeping in mind
the economic status of the patient.
 Personal Hygiene — Explain the importance of maintaining personal hygiene and
wearing clean loose comfortable clothes. High heel shoes should be avoided.
 Care of the breast hygiene and supporting undergarments.
 Dental Care — If any dental problem is there refer to the dentist
 Antenatal Exercises — Demonstrate and advise the importance of antenatal exercise
and of rest and sleep
 Regular medication and supplementation
 Care of the Bowel — Avoid constipation by taking in plenty of fluids and a balanced
diet
 Posture — Maintain proper posture and change posture frequently. Avoid supine
position if necessary keep a small pillow under lower back.
 Immunization — Advice about immunization; 2 doses of tetanus toxoid.
 Travel — Travel in jerky movements is to be avoided. Avoid long journeys.
 Explain about warning signs like:
 Bleeding per vagina
 Leaking per vagina
 Convulsions or coma
 Epigastric pain
 Blurring of vision
 Sever headache
 Oedema, etc.

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Advise about preparation for confinement and articles to be kept ready for delivery.
Explain about signs of true labour and when to contact for help or confinement.
IDENTIFICATION OF RISK FACTORS

 Identify the risk factors and assess the risk status of pregnant women.
 Every pregnancy carries an element of risk even if the previous pregnancy is normal.
Risk factors must be taken into account while examining the mother e.g.:
 Height — Short stature woman
 Age — Less than 20 or more than 35
 Parity — Multiparty or more than five
 Education — Illiterate or below primary level
 Socio-economic status — Low
 Weight gain during pregnancy — More or less more than normal range ·
Weight of the mother less than 45 kg or than 90 kg.
 Previous pregnancy — Bad obstetrical history, previous caesarian ·
Present pregnancy:
 Any medical problem — acute or chronic
 Bleeding per vagina
 Pregnancy induced hypertension
 Rh negative pregnancy
 Abnormal uterine growth — Big baby/IUGR
 Presentation — Abnormal presentation/multiple pregnancy
 Anaemia — Hb below 10 gms %
 Previous pregnancy — Prolonged labour
 Foetal Distress
 Post partum haemorrhage
 Previous factors, neonatal factors may be enquired like history of foetal distress,
neonatal jaundice, low birth weight (<2500 gms), congenital malformations
 These information will help in identifying mothers at risk and appropriate action may be
taken.
 Prompt recognition of the problems
 Proper utilization of the health facilities
 Adequate care and referral
 Prevention of complications

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Bibliography
 Annamma Jacob “COMPREHENSIVE TEXTBOOK OF MIDWIFERY AND
GYNECOLOGICAL NURSING”,3RD edition; jaypee publisher, New Delhi .
 D.C.Dutta “ TEXTBOOK OF OBSTETRIC AND GYNAECOLOGICAL NURSING’,8 TH
edition; jaypee brother publisher, New Delhi.
 Nimma Bhaskar “MIDWIFERY AND OBSTERICAL NURSING” 1ST edition Emess
medical publishers, banglore.
 Dharitri Swain “ Obstetric Nursing Procedure Manual “ jaypee brother publisher, New
Delhi.

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