KGMU, COLLEGE OF NURSING

LUCKNOW, U.P.

Subject: Obstetric and Gynaecological Nursing

ANTENATAL assessment

SUBMITTED TO: SUBMITTED BY:

Mrs. Sarita Dubey Miss. Neha Singh

Clinical Instructor M.Sc. N (II)

KGMU, College of Nursing KGMU, College of Nursing

ROCEDURE OF ANTENATAL HISTORY COLLECTION AND ANTENATAL
EXAMINATION

INTRODUCTION

Systematic examination and history collection of a woman during pregnancy is called antenatal
examination and history collection.

Aims and Objectives

1. To promote and maintain good physical, mental and emotional health of the mother.
2. To ensure a mature, healthy and alive baby.
3. To prepare mother for labour, lactation and subsequent care of the child.
4. To detect early and treat promptly, high-risk conditions (medical, surgical or obstetrics)
that may endanger life of the mother or baby or both.
5. To prevent, detect and to treat at the earliest any untoward complications that may arise.
6. To reduce maternal morbidity and mortality rates.
7. To prepare mother to adopt small family norm.
8. To give required health education to the mother.

Objective
Objective of antenatal examination is to ensure a normal pregnancy with delivery of a healthy
baby from a healthy mother.

PROCEDURES IN ANTENATAL EXAMINATION

(a) Set-up of an antenatal clinic.
(b) Assess antenatal mother.
(c) Registration and history taking.
(e) Head-to-toe examination i.e. general and systemic examination.
(f) Obstetrical examination/abdominal examination.
(g) Vaginal Examination.
(h) Detect mother with high risk pregnancy.
(i) Antenatal Education including education on Diet, Breast Care and Antenatal Exercises.
(j) Antenatal examination also includes laboratory tests and radiological examination.

A. SET-UP OF AN ANTENATAL CLINIC

 Facilities required to conduct examination are:

  A room with proper lighting.
 There should be window for ventilation.
 Temperature of the room should be according to season.
 Examination table with bed length mattress, mackintosh and bed sheet spread on it and a
pillow for comfort of the woman. Facility for the woman to pass urine.
 Hand washing facility for care provider.

Equipments Needed
 Weighing scale.
 Measuring scale for taking height.
 Torch.
 BP apparatus and stethoscope.
 TPR tray.
 Screen and draping sheets to maintain privacy.
 Extra pillows for comfort of women.
 A tray containing urine analysis articles.
 A covered glass with water and glucose powder.
 Fetoscope.

Prerequisites
 Explain procedure and provide essential information.
 Have gentle approach and matter of fact attitude.
 Have all the equipments necessary for the procedure in proper place to avoid interrupting
 the examination.
 Ensure privacy for examination without unexpected intrusion. (gowns and drapes may be
given)
 Environment should be comfortably warm and pleasant. (examiner must warm hands).
 Ask patient to empty bladder and obtain urine specimen.

B. ASSESSMENT OF ANTENATAL MOTHER

History Taking

During woman's first visit to antenatal clinic, registration is done and antenatal card is made. It is
also important to obtain a baseline information to assess health status of the woman, steen out
high risk cases and formulate the plan of subsequent management,

Identification Data
This includes name, age, address and marital status.
Demographic Data
Demographic information identifies the client, her residence, age, race and religion, marital
status and
occupation. Exploring her replies and observing her behaviour may collect important
information.

Menstrual History
It is an important part of data collection in all female clients whether pregnant or non-pregnant.
It is important to know the age when the menstruation first occurred (menarche), the regularity of
the periods, the duration and amount of menstrual flow, any pain associated with periods.

Calculating Expected Date of Delivery

The average length of pregnancy is 280 days, 10 lunar months or 40 weeks.

EDD can be calculated

According to this rule EDD can be calculated by adding 9 calendar months +7 days to the 1st day
According to this rule EDD can be calculated by adding 7 days to 1st day of LMP.

Dating Pregnancy When LMP is Unknown parameters

Many a times we come across women who are unable to remember their LMP. The which we
use to determine the length of gestation, are as follows:
 Presence of uterus in the pelvis. (indicates pregnancy of less than 12 weeks of gestation)
 Presence of uterus in abdomen indicates pregnancy of more than 12 weeks
 Fundus of uterus at the level of umbilicus indicates pregnancy of 24 weeks.
 Quickening is felt at 18–20 weeks in primigravida and earlier in multigravida.
 Sonography-can be used to determine gestational age accurately.
 McDonald's rule.

Past Medical History

Medical illnesses must be elicited. It is necessary to have some knowledge of the woman's
previous health as former illnesses may have damaged certain organs or structures and this might
give rise to complications during pregnancy or labour. TB of hip and spine may cause
deformities in the pelvis. Rheumatic infections may lead to cardiac impairment; diseases like
nephritis tend to aggravate by child bearing; diabetes and cardiac disease may complicate
pregnancy and labour; and syphilis and diabetes can both endanger life of the child. Previous
history of steroid therapy, blood transfusion, bronchial asthma, rickets and osteomalacia are to be
enquired.

Surgical History
Any surgeries major or minor, general abdominal or gynaecological, performed in the past are to
be mentioned in the history. Any history of blood transfusion is also recorded.

Family History
Any family history of hypertension, diabetes, asthma or venereal disease, twin retardation is to
be enquired, Family history of hypertension and diabetes may predispose the woman to these
diseases. Maternal side history of twin pregnancy is important to elict as women may be
predisposed to twin pregnancy. If her mother for maternal grandmother have history of twin
pregnancy. History of mental retardation in family may indicate chromosomal abnormalities.

Personal History
Literacy and qualification of the woman, duration of marriage and any personal habits e.g.
alcoholism,
Smoking are to be elicited and mentioned in the history. Alcoholism and smoking lead to IUGR
in baby.

Obstetrical History
Obstetrical history refers to a record of previous pregnancy, labour and puerperium. The
obstetrical
History provides important data that may be useful and in anticipating and managing
complications

The history of pregnancy may be recorded by using mnemonics G, P, A, L.

G: Gravida; it denotes pregnant state both present and past irrespective of the period of gestation
P: Parity denotes a state of previous pregnancy beyond the period of viability.
A: Denote abortions.
L: Denotes number of live children.

History of Present Pregnancy

It is usually the presumptive sign of the pregnancy that bring a woman to care. A review of
symptoms, that she is experiencing and how is she coping with them helps to establish an
enquiry should be made about the general condition of the woman, her appetite, sleep, bowel
habit. Genesis of present complaints is to be noted stating the mode of onset, duration and
progress. its, urination, morning sickness, fatigue and breast discomfort or any other discomfort,
which maydevelop a plan of care.

C. HEAD-TO-TOE EXAMINATION

Physical Examination
Physical examination begins with assessment of vitals, height, weight and urine analysis for
albumin and sugar.

Vitals and BP: These must be recorded at each visit. At first visit in First trimester a baseline
data regarding vitals should be obtained and compared with subsequent reading to detect any
changes at the earliest that might occur during pregnancy.

Height: Short stature in pregnant women is regarded as a high risk factor because of its
association with small pelvis.

Weight; Weight is an important parameter to be recorded at every visit preferably on the same
machine. Machine should also be checked for its accuracy intermittently. Stationary or
decreasing weight is found in IUGR. Rapid gain in weight of more than 0.5 Kg/week is one of
the manifestations of pre-eclampsia.

Urine analysis: Presence of albumin in urine is indicative of pre-eclampsia/kidney diseases.

Presence of sugar in urine at more than two occasion calls for investigation like blood sugar and
GTT to exclude diabetes in pregnancy.

General Physical Examination

Head to toe examination should be conducted in all patients to get information of any relevant
findings May influence the approach to the management of pregnancy in patients.

Built

May be obese/average/thin. Obesity is associated with multiple medical illnesses like

hypertension, cardiac illnesses and diabetes. Obese women are likely to tire out quickly during
labour. Thin built women should be assessed for any evidence of malnutrition, anemia, vitamin
deficiencies, poor weight gain etc.

Gait

Normal/Any abnormality. Some changes in gait is a normal feature in late pregnancy. However
certain pelvic deformities arising due to orthopaedic illnesses (Including osteo-malacia) cause
unusually abnormal gait and may be suggestive of pelvic inadequacy. Appearance: May be
depressed, tired and lethargic. Pregnancy being a high stress phase in the life of women; noting
the evidence of obvious psychological stress helps the nurse to provide appropriate counseling
and advising the near ones for emotional support.
Head

Examination of scalp for cleanliness, infection and infestations and hair for their luster and
texture and nits is carried out. Texture and luster of hair reflects the nutritional status of the
mother. Presence of nits is due to pediculosis.

Eyes

Palpebral conjunctiva for pallor, sclera for jaundice and eyes for evidence of infection.

Nose

Deviated nasal septum, infection and blockage.

Mouth

Observe tongue for pallor, glossitis (Vitamin deficiencies), teeth and Gums for dental caries,
stomatitis, tonsils for tonsillitis.

Ear

Infection, blockage, wax. (Assessing scalp, hairs, eyes, nose, orodental health and ears for
infections/Infestations is important because low grade infections that may keep on occurring in
these areas during pregnancy impair the feeling of well being of the women who is already going
through a phase in which physical and psychological stresses of the pregnancy itself are quite
discomforting. Secondly, infections in these areas are often overlooked and these may be the
source of autogenous infection during puerperium. Thirdly it is important for the nurse clinician
to inculcate a habit to view the patient as a whole.)
Neck

Observe neck veins, thyroid glands, lymph glands for any abnormalities.

Upper Extremities

For any bony abnormalities.

Examination of Breast

Breast should be examined for size, symmetry, dimpling, lesions, masses, areas of thickening,
tenderness, areas of inflammation, presence of scars. Nipples should be examined for their
development (whether inverted, underdeveloped or cracked), discharge, crusting, and presence of
scars, lymph nodes are assessed for size condition and tenderness.

Normal Changes in Breast during Pregnancy

 3-4 weeks: Prickling, tingling sensation (stimulated by ovarian hormones i.e. oestrogen
and progesterone).
 6 weeks: Enlarged and tense.
 8 weeks: Surface veins are visible.
 8 weeks: Montgomery's tubercles appear.
 12 weeks: Darkening of primary areola.
 12 weeks: Fluid can be expressed.
 16 weeks: Colostrum can be expressed.
 16 weeks: Secondary areola appears.

Lower Extremities

Legs should be looked for oedema and varicosities. Homan's sign (calf pain on dorsiflexion of
foot may be elicited to diagnose deep vein chrombosis. Oedema may be physiological or may
associated with preeclampsia, anaemia, hypoproteinemia, cardiac failure and nephrotic
syndrome. Physiological oedema is due to increased venous pressure in the lower extremities
caused the growing uterus pressing on the common iliac veins. The features of physiological
oedema are ankle oedema, disappears on rest, not associated with high B.P. and/or proteinuria
Midwife should test for picting oedema in the lower limbs by applying fingertip pressure for 10
seconds over the tibia bone. If picting oedema is present a depression will remain when she
removes her fingers.

Back

Back is to be examined for lordosis, scoliosis and kyphosis. Lower back may be looked for
thomboid of Mechales. The landmarks for rhomboid of mechales are 5th lumbar vertebra above,
gluteal cleft below and dimples of posterior superior iliac spines on the sides.

D. OBSTETRICAL EXAMINATION

Objectives
1. To diagnose the lie. Presentation and position of foetus.
2. To detect cephalopelvic disproportion
3. To know whether the pelvis is adequate or not.
4. To detect any abnormality: Twins, hydramnios, fibroids, malpresentations, ovarian tumourse
etc.

Obstetrical Examination Includes

1. Abdominal examination.
2. PV examination.

1. Abdominal examination

Preliminaries

 Woman must evacuate bladder to aid her own comfort and for examination to be reliable.

 A full bladder places upward pressure on the uterus, causing it to rise higher in to the
abdomen. Not only does this cause discomfort to the patient, but erroneous measurement
maybe made when the bladder is mistaken for uterus.

 Woman to lie in dorsal position with thighs and knees slightly flexed. Elevate the head of
the examination table slightly. This helps in easing the tension of the abdominal muscles,
allowing easier palpation.

 Maintain privacy, exposing only abdomen. (Woman can lie comfortably with arms by her
side and legs covered).

 Examiner to stand on the right side of the patient

 Examiner to wash and warm hands before touching the abdomen. Cold hands will irritate
abdominal and uterine muscles, which maygo into contractions and woman represents the
discomfort caused by them.

 Examiner arms and hands should be relaxed. Nails should be trimmed. Use pads and not
the tips of the ingers.

 Move hands in a stroking motion in order to avoid contractions

Steps of abdominal examination

1. Inspection.
2. Palpation.
3. Auscultation.
Inspection

The lie of the foetus: Ovoid of uterus may be longitudinal or transverse or oblique.

Contour of the uterus: Fundal notching, convex or flattened anterior wall, cylindrical or twin
pregnancy spherical shape.

Undue enlargement of the uterus. It may be due to polyhydramnios

Skin conditions of abdomen for any evidence of infections eg, scabies and ring worm, di
protrude and may become sensitive) lated veins, pulsations, irritation and condition of the
umbilicus.

Scar marks on abdomen, which may be indicative of previous LSCS or abdominal surgery
like laprotomy

Cutaneous changes
Linca nigra (the dark line of pigmentation seen running longitudinally in the center of the
abdomen below the umbilicus.), striae gravidarum (silvery streaks suggest a previous pregnancy;
pink streaks occur in present pregnancy).

Measurement of fundal height

Fundal height and abdominal girth are measured in centimeters and inches respectively. It
provides information about the progressive growth of pregnancy and foetus and is an important
part of the antenatal assessment. The zero line of a centimeter measuring tape is placed on the
upper edge of the symphysis pubis and the tape is brought over the abdominal curve to the top of
the fundus.

Estimation of Fundal Height

It is calculated as follows:
Height of fundus in cm x 2/7 (or +3.5) - Duration of Pregnancy in lunar months.
Height of fundus in cm x 8/7 - Duration of Pregnancy in weeks.
After 20 weeks of gestation, the fundal height (measured in centimeters) approximates the weeks
of pregnancy up to 36 weeks. Before 20 weeks of gestation the uterus is measured in fingers. An
alternative popular method is to measure the symphysis fundal height in weeks. Following
breadths above the symphysis pubis or below the umbilicus.
2. PALPATION
Palpation should be conducted gently taking care of woman's comfort palpating woman
abdomen without any purpose is not only fudle but also can cause undue uterine inability
Palpation should be conducted during contractions.

Obstetrie grips
1. Fundal grip
2. Lateral grip
3. Pelvic grip
4. Pelvic grip II or Pawlies grip
5. Combined grip
6. Engagement of the Head

1. Fundal grip

Fundal grip is conducted facing the woman's head. The whole of the fundal area is palpated with
both hands using the palmer surface of the fingers and keeping the fingers close and tight.
Deliberate pressure is applied to determine the broad soft consistency and irregular outline of the
breech Smooth hard globular mass is suggestive of head. He al mass is grasped with a gliding
movement while slightly separating the fingertips. It helps in ascertaining the size and mobility.
The breech cannot be moved independent of the body as can be the head, while the head can be
balloted between the fingertips of the two hands because of the free movements of the neck.

2. Lateral grip

Both hands are moved on either side of the uterus at about umbilicus level (as a movement
continuousfrom the fundal grip). Apply pressure gently with alternate hands to detect as to which
position the fetus is lying in. Both hands are moved down the length of the abdomen using
sliding movement while feeling both sides of the uterus alternately. In LOA back is felt as a
continuous smooth and regular mass from breech to neck on left side and limbs are palpated on
right side as irregular small parts. In ROA back is felt on right side and limbs are felt on left side.

3. Pelvic palpation

This is done to determine the presentation, position and presenting part of the foetus. This helps
in diagnosing the engagement of the foetal head of the uterus with the thumb on the right side
and the fingers on the left side of the uterus. The fingers and thumb of the right hand should be
wide spread with ulnar border on the upper border of the symphysis pubis to accommodate the
fetal head. The woman is asked to take a deep breath and to exhale slowly through open mouth.
This grip is to be carried out with great gentleness, as any undue pressure will cause discomfort
and pain to the expectant mother.
4. Pawlik’s grip

The third maneuver was modified by Karel Pawlík (1849–1914), a Czech gynecologist and
obstetrician, and is referred to as the Pawlik grips. This maneuver aids in confirmation of fetal
presentation.
The first Pawlík grip, sometimes called the first pelvic grip, helps to define which presenting part
of the fetus is situated in hypogastrium. Using the thumb and fingers of the right-hand close
above the pubic symphysis, the presenting part is grasped at the lower portion of the abdomen
and draws the thumb and finger near to clasp the lower uterine segment including its contents.
In the second Pawlík grip, the clinician carries on by sliding the hand upward to determine the
cervical groove: if the mass moves, the presenting part is not engaged. Then lateral movements
and ballottement are performed. The differentiation between head and breech is made as in the
first maneuver. This maneuver also allows for an assessment of the fetal weight and the volume
of amniotic fluid.

3. Auscultation

Auscultation Procedure:

 Explain the procedure to the woman and her support person(s).

 Assist the woman to a semi-Fowler's or wedged lateral position.
 Palpate the maternal abdomen while performing Leopold's maneuvers.
 Assess uterine contractions (frequency, duration, intensity) and uterine resting tone by
palpation.
 Apply conduction gel to underside of the Doppler.
 Position the bell of the Doppler on the area of maximum intensity of the fetal heart sounds
(usually of the fetal back).
 Place a finger on the woman's radial pulse to help differentiate from FHR.
 Count the FHR after uterine contractions for at least 60 seconds.
 To clarify FHR increases and decreases, counting for multiple, consecutive brief periods
of 6-10 seconds (multiplying by 10 and 6 respectively) may be particularly helpful.
 Interpret FHR findings and document rate, rhythm, presence of increases or decreases and
their relationship to the contraction.
 Share findings with physician, patient and her support person(s) and answer
questions as needed.
 Promote maternal comfort and continued fetal oxygenation.

Interpretation:
Interpretation of Auscultation Findings

FHR characteristics auscultation include all of the following:

• Normal FHR baseline between 110 and 160 bpm
• Regular rhythm
• Presence or absence of FHR increases from the baseline rate
• Absence of FHR decreases from the baseline rate
 Indeterminate or Category II: FHR characteristics by auscultation include any of the
following:
• Irregular rhythm
• Presence of FHR decreases from the baseline rate
• Tachycardia (baseline > 160 bpm > 10 minutes in duration)
• Bradycardia (baseline < 110 bpm > 10 minutes in duration)

VAGINAL EXAMINATION

Performing a cervical screening

Cervical screening is recommended for women every 5 years. Cervical Screening in early
pregnancy is safe and does not cause miscarriage.

Checking signs of an infection

The hormones of pregnancy affect the environment of the vagina, making you more prone to
thrush or an overgrowth of vaginal bacteria (called ‘Gardnerella’). A vaginal examination
with a speculum can help making the diagnosis and if required, a swab tests is needed.

Looking for a cause of bleeding

If you experience bleeding during your pregnancy a vaginal examination with a speculum is
needed to try and find out the cause of the bleeding.

Sweeping (or Stripping) the membranes

Or a ‘strip and stretch’. It involves a vaginal examination, by placing 2 gloved fingers

through the opening of the cervix and then separating the membranes or sac (holding the
waters and baby), from their slight attachment to the lower segment of the uterus. The aim is
to trigger a local release of Prostaglandin hormones by the cervix and perhaps induce
labour.

Sweeping the membranes can be quite uncomfortable for the woman and sometimes a small
amount of bright red bleeding for 24 hours or so afterwards.

Making decisions about induction methods

The position, softness and openness of the cervix need to be assessed to make decisions
about the best way to perform an induction of labour.

Seeing if the waters have broken

If you think your waters have broken, contact your hospital you are booked in for advice.
Keep any pads or underwear and take them with you. If there is some doubt as to whether
your waters have broken, the following methods are used to try and determine if they
definitely have by:

 A speculum examination to see if water is coming away from the cervix.

 AmniSure test.

How a vaginal examination is done

Gloved fingers

This involves the woman partially undressing from the waist down and lying on her back on
the bed, resting comfortably with her knees bent, feet together and allowing her knees to fall
comfortably apart. The doctor usually puts a small amount of K-Y gel and places their first
2 fingers inside the woman’s vagina until they feel her cervix.

A speculum

This is a metal or plastic instrument, shaped a little like a duck’s bill. The woman needs to
lie on her back on the bed and rest comfortably with her knees bent.
Her bottom needs to rest on the lower edge of the bed and her feet are usually placed on a
slightly lower platform, at the bottom of the bed. This position helps makes the procedure
less uncomfortable. The end of the speculum is gently slide into the vagina. Once in place,
the ‘bills’ of the instrument are opened slowly, this separates the walls of the vagina,
allowing the doctor to look inside and view the woman’s vagina and cervix.

C. DETECTION OF HIGH RISK PREGNANCY

Peany complicated by one or more factor which adversely affects the outcome of pregnancy

mammal, perinatal or both. Pregnancy and child birth is considered to be a period of risk
forwoman.

But there are certain pregnancies in which fetus and mother are at higher risk. It is important
to

identity these high risk cases and give them special care to reduce maternal mortality and
morbidity
Screening of high risk cases begins from the Ist antenatal visit in the Ist trimester of
pregnancy.

Highscreening may be carried out by trained midwives and the cases may be referred to
higher

mwer frequired for management by specialists. Screening continues throughout pregnancy

on cach

and woman is reassessed at term and at the onset of labour for detection of any new risk
factors,

Methods of Screening

1. History taking

2. Eumination

General physical examination

Obstetrical examination

1. History Taking

Maternal age: Below 17 years and above 35 years, Ist conception after 30 years of age (el-

derly primigravida), history of infertility and consumption of ovulation inducing agents.

- Family history: Women belonging to low socio-economic status, (risk of anemia, IUGR,
pre-

tem labour is high) family history of diabetes, hypertension, cardiac diseases, tuberculosis,

history of multiple pregnancy (maternal side), History of chromosomal or congenital mal-

formation

Medical and surgical history: History of medical illnesses eg. heart disease, diabetes, renal

diseases, tuberculosis. liver disorders (hepatitis), hypothyroidism or hyperthyroidism, psy-

chiatry illnesses. History of any previous operations like abdominal surgeries, operations in

the productive organs eg. myomectomy, repair of VVF or stress incontinence, repair of

perincaltar

. History of blood transfusion

Obstetrical history: Woman with history of normal delivery in the past has low risk in

the subsequent pregnancies. High risk factors include history of abortion, MTP, IUD or

still birth, neonatal death and congenital anomalies. History of birth of

or baby weighing more than 3.5kg grand multipara, previous LSCS, Forceps delivery, his-

rory of malposition or malpresentation, pre-eclampsia, APH, anemia, PPH, Rh or ABO

incompatibility

2. Examination

General physical examination: Height below 145cm, weight less than 40kg or over weight

(BMI of 20-24 is normal) and blood pressure measuring more than 130/90mm Hg are

considered high risk. Pallor indicates anemia, presence of cardiac or pulmonary diseases are

also high risk conditions for pregnant women.

() Pelvic examination: Smaller uterine size indicates IUGR while bigger uterine size
indicates

hydramnios, big baby or twins. Pregnancy with genital prolapse, tumours, cervical
lacerations

and inadequate pelvis increase the risk of pregnancy. Certain factors present in different

trimesters of pregnancy are also responsible for risk to pregnancy and child birth. During

Ist trimester history of threatened abortion, hyperemesis gravidarum, pre-existing anemia,

Rh- isoimmunization and history of exposure to drugs or radiation are looked for. Dur-

ing 2nd trimester women with high BP, anemia, high fever, pyelonephritis, haemorrhage,

DM, large uterine size i.e. hydramnios, DM, multiple pregnancy or small uterine size i.e.

IUGR (both associated with placental dysfunction) should

be given special care. High risk

factors in 3rd trimester are post maturity, floating head, abnormal presentation, PROM

and preterm labour. High risk scoring can be done as under:

Score

Risk Factors
1

1. Age less than 18 years or more than 35 years.

2. Maternal height less than 145 cm.

3. Primi or multi more than 5.

4. Bad obstetrical history.

5. History of neonatal Jaundice or Rh ABO incompatibility.

6. Weigh less than 45 kg. or more than 90 kg.

7. History of low birth weight.

8. Previous uterine surgery.

9. History of APH or PPH.

10. History of manual removal of placenta.

11. Anaemia (less than 6 gm per cent).