ASSESSMENT OF MATERNAL MEASURES AND PRENATAL

COUNSELLING
INTRODUCTION:
Assessment means is to evaluate i.e. here we gather the information of client status and it
identifies the specific needs of a client by which better care can be given to the client and her
developing fetus. That means, it is the systematic supervision (examination & advice) of a
women during pregnancy.

TERMINOLOGIES:
 Prenatal: the term prenatal means the period of time before delivery.
 Gravida: the number of time a women has been pregnant.
 Primigravida: pregnant for first time.
 Multigravida: pregnant more than once
 Parity: the number of times that she has given birth to a fetus with a gestational age of
20 weeks or more.
 Hyper emesis: persistent nausea and vomiting during pregnancy.
 Ante partum haemorrhage: it is defined as bleeding from or into the genital tract,
occurring from 22 weeks of pregnancy prior to the birth of baby.
 Pre-eclampsia: new hypertension presenting after 20 weeks with significant
proteinuria (>300mg protein in 24h)
 Dyspnoea: it is defined as difficult or laboured breathing or the unpleasant awareness
of one’s breathing.
 Linea nigra: a dark vertical line that may appear down the centre of a women’s
abdomen during pregnancy.
 Amenorrhea: it is defined as the absence of menstruation.
 Counselling: It is defined as the service of helping people to adjust to or deal with
personal problems by enabling them to discover for themselves the solution to the
problems while receiving attention from a counsellor.

ASSESSMENT OF MATERNAL MEASURES

INTRODUCTION:
Assessment means is to evaluate i.e. here we gather the information of client status and it
identifies the specific needs of a client by which better care can be given to the client and her
developing fetus. That means, it is the systematic supervision (examination & advice) of a
women during pregnancy.

Definition:
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 checkup.

MATERNAL MEASURES:
1. History taking

2. General examination:

(i)Physical

(ii)Obstetrical examination

3. Routine examination

4. Special investigation

1. History taking:

 Vital statistics:
 Name
 Date of first examination
 Address
 Age
 Gravid: parity: gravid and Para refer to pregnancies and not to babies. As such, a
woman who delivers twins in first pregnancy is still a gravid one and Para one.
 Duration of marriage
 Religion
 Occupation
 Period of gestation: the duration of pregnancy is to be expressed in terms of
completed weeks. A freaction of a week of more than 3 days is to be considered as
completed week. In calculating the weeks of more than 3 days is to be done from the
first day of last normal menstrual period (LNMP) and in later months of pregnancy,
counting is to be done from expected date of delivery (EDD).
 Complaints: categorically, the genesis of the complaints is to be noted. Even if there is
no complaint, enquiry is to be made about the sleep, appetite, bowel habit and
urination.
 History of present illness: elaboration of the chief complaints as regard their onset,
duration, severity, use of medications and progress is to be made.
 History of present pregnancy: the important complications in different trimester of the
present pregnancy are to be noted carefully. These are hyper emesis and threatened
abortion in first trimester; features of pyelitis in second trimester and anaemia, pre-
eclampsia and ante partum haemorrhage in the last trimester.
 Obstetric history: status of gravid, parity, number of delivery, miscarriage, pregnancy
termination and living issue.
  Menstrual history: cycle, duration, amount of blood flow and first day of the last
normal menstrual period are to be noted. From the LNMP, the expected date of
delivery has to be calculated.
 Past medical history: relevant history of past medical illness (urinary tract infections),
tuberculosis) is to be elicited.
 Past surgical history: previous surgery-general or gynaecological, if any, is to be
enquired.
 Family history: family history of hypertension, diabetes, tuberculosis, blood dyspraxia,
known hereditary disease, if any, or twinning is to be enquired.
 Personal history: contraceptive practice prior to pregnancy, smoking or alcohol habits
are to be enquired. LMP may be withdrawal bleed following pill usage. — Health
habits like smoking, drinking, drugs or any other past medical history.

2 .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 kgs. 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: The Bp is the most important vital sign that should be monitored every clinic
visit. There is usually no significant change in Bp during gestation. However, expect a slight
drop in the 2nd trimester that returns to normal on the 3rd trimester. Blood pressure should be
recorded during each visit. Any reading above 140/90 should be reported.

Pulse rate: pulse rate increases by about 10 bts/min. Due to increased cardiac workload.
Arrhythmias or palpation are normal during pregnancy as long as it is not accompanied by
dizziness and syncope.
Respiratory rate: increase in depth, no significant change in rate. Shortness of breath and
dyspnoea late in pregnancy is common.

Temperature: there is slight elevation in temperature early in pregnancy due to the

thermogenic effect of progesterone. It drops to normal after 16 weeks.

Physical assessment:

a. Hair and scalp- hair tends to grow faster during pregnancy. Oily hair is also not
uncommon. Excess hair dryness indicates poor nutrition.
b. Eyes- pale conjunctiva indicates anaemia. Edema of the eyelids accompanied by visual
disturbances is sign of PIH.
c. Nose- normal nasal congestion occurs as a result of oestrogen stimulation.
d. Ears- nasal stiffness results in blockage of the Eustachian tube which may affect
pregnant woman’s hearing.
e. Mouth and teeth- it is normal to find swollen gums due to oestrogen stimulation.
Cracked corners of the mouth may be caused by vitamin deficiency which pregnant
women are prone to develop. Dental carries should be treated during pregnancy as
they may become site of infection.
f. Neck- slight thyroid enlargement is brought about by increased basal metabolic rate.
g. Breast- normal finding include enlargement of the breast with wider and darker
areola, prominent veins. Breast masses, nodules, dimpling of the skin and bloody
nipple discharge are abnormal findings and should be reported to the physician right
away.
h. Skin- linear Negara, mask of pregnancy (melasoma/chloasma), spider nevi, palmer
erythema are common findings. Pallor, jaundice, rashes and skin lesions are abnormal
findings.
i. Back- exaggerated lumbar curve late in pregnancy occurs as a result of the shifting of
the pregnant woman’s centre of gravity.
j. Rectum- haemorrhoids may be present especially in the last months of pregnancy.
k. Extremities- ankle swelling is a normal finding in the 2nd half of pregnancy. Leg
especially in the late afternoon is common to pregnant women. Waddling gait is due
to relaxation of pelvic joint. Edema of upper extremities, face and hands are danger
signs.

(ii)Abdominal Examination

A thorough abdominal examination of pregnant woman helps to determine the lie, presentation,
and position of the fetus.
General Instructions to be kept in mind during abdominal examination: ·
o Pressure to palpate the returns ·
o Palpation should be continuous i.e. do not lift your hand till the whole palpation is
done.
 o Follow the four sequential steps of palpation (Leopoldsmanouever). This will help you
to gain and improve accuracy of your findings maneuver. · 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 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.
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 palpation is done using 5 types of grips
which are:
1) Fundal Grip
2) Lateral Grip
3) Pelvic Grip — Deep Pelvic palpation
4) Pelvic Grip — PawlickManoeuver
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 mostlylongitudinal 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 is mostly vertex (head)

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.

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.

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 alternates 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 give an indication of its general length. This may be possible after 18 to 20 weeks.
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 confirm that the examiner is
learning the foetal heart beat rather than that of the mother. If the foetalheart 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.

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 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

Routine investigations:
 Blood: hemoglobin, hematocrit, ABO, Rh grouping, VDRL are done. Blood glucose
and antibody screening are done in selected cases.
 Urine: protein, sugar and pus cells. If significant proteinuria is found is found, “clean
catch” specimen of midstream urine is collected for culture and sensitivity test. To
collect the midstream urine, the patient is advised to clean the vulva and to collect the
urine in a clean container during the middle of the act of urination. Presence of nitrites
and or leukocyte esterase by dipstick indicates urinary tract infection.
 Cervical cytology study: by papanicolaou stain has become a routine in many clinics.

Special investigations:
 Serological tests for rubella, hepatitis B virus and HIV- antibodies to detect rubella
immunity and screening for hepatitis B virus and HIV.
 Genetic screen: maternal serum Alpha feto protein(MSAFW) triple test at 15-18 weeks
for mother at risk of carrying a fetus with neural tube defects, down syndrome or other
chromosomal anomaly.
  Ultrasound examination: first trimester scan either transabdominal (TAS) or
transvaginal(TVS) helps to detect:
(i) Early pregnancy
(ii) Accurate dating
(iii) Number of fetuses
(iv) Gross fetal anomalies
(v) Any uterine or adrenal pathology. Use of ultrasound should be selective rather than
a routine.

Prenatal counseling:
Antenatal counselling is a technique of assessing the presence of genetic disorders in an
unborn child.

Antenatal counselling is done in individuals with a family history of genetic disorders.

It is recommended for pregnant women and also in couples who are planning to have a baby.

Preconceptional/ prepregnancy counselling

When a couple is seen and counselled about pregnancy, its course and outcome well before
the time of actual conception is called preconceptional counselling.

Objective is to ensure that a woman enters pregnancy with an optimal state of health which
would be safe both to herself and fetus.

Principles:
 To impress the women about the importance of the regular checkup.
 To maintain or improve the health status of the women to the optimum till delivery by
judicious advice regarding diet, drugs and hygiene.

 To improve and tone up the psychology and remove fear about pregnancy and the
labour.
 Instruct the pregnant women on the importance of regularly scheduled follow-up
visits.
 Instruct the pregnant mother on the importance of personal hygiene.
 Instruct the pregnant mother on the importance of proper nutrition.
 Instruct the pregnant women on the importance of proper rest and sleep.
 Instruct the pregnant women about the dental care.
 Instruct the pregnant women on activity modification during pregnancy like
employment, travel, sexual relations, alcohol consumption, smoking, do not eat raw
meats to prevent toxoplasmosis, exercise.
 Instruct the mother on importance of bowel elimination.
 Instruct about the vaginal douching.
 Instruct about the importance of clothing.
 Exposure to infection irradication.
 Instruct the patient on potential dancer sign/ warning sign of pregnancy that would
necessitate her contacting her physician and coming in.
SUMMARY:
Systematic supervision (examination and advice) of a woman during pregnancy is called
antenatal (prenatal) assessment. The supervision should be regular and periodic in nature
according to the need of the individual.Careful history taking and examination (general and
obstetrical), Physical assessment, routine investigation .

CONCLUSION:
Antenatal care is an essential aspect of health care delivery for improving pregnancy out
come. By this service we can detect high risk pregnancies and we can direct them for proper
management.

Research abstract
Background: The maternal health status of Indian women was noted to be lower as compared
to other developed countries. Promotion of maternal and child health has been one of the most
important components of the Family Welfare Programme of the Government of India. For
sustainable growth and development of country, there is a need to improve MCH Care in the
country. Safe motherhood by providing good antenatal care (ANC) is very important to reduce
maternal mortality ratio and infant mortality rate and to achieve millennium development
goals. Objectives: This study aimed to determine the level of knowledge, attitude, and practice
on ANC among pregnant women attending the antenatal clinic at a Tertiary Care Hospital in
Pune and their association with various sociodemographic factors. Materials and Methods: A
cross-sectional study was carried out among 384 pregnant women in their 3 rd trimester
attending the antenatal clinic in a Tertiary Care Hospital of Pune, Maharashtra during October
2011 to September 2012. Pretested questionnaire was used for collecting data by interview
after obtaining informed consent. Statistical analysis was performed using SPSS version 20 and
Epi Info Software. Results: Study reveals that about 58% women had adequate knowledge
regarding ANC. It was found that almost all the variables such as age, education, occupation,
parity, type of family, and socioeconomic status (SES) had a significant association with
awareness about ANC. 100% women were having a positive attitude toward ANC. Around
70%, women were practicing adequately, and variables such as education and SES had a
significant association with practices about ANC. Conclusion: These findings can be used to
plan a Health Intervention Program aiming to improve the maternal health practices and
eventually improve the health status of the women.
BIBLIOGRAPHY:
DC Dutta’s, text book of obstetric, 8th edition, jaypee brothers medical publishers

Annamma Jacob, a comprehensive textbook of midwifery and gynaecological nursing, 3 rd

edition, jaypee brothers medical publishers

Nimabhaskar, midwifery and obstetrical nursing 2nd edition, hardiya publication

https://www.ncbi.nih.gov>pubmed

https://www.jacksonnvilleu.com
GOVERNMENT COLLEGE
OF NURSING, JODHPUR
(RAJ.)

TOPIC- ANTENATAL ASSESSMENT

AND PRENATAL COUNSELING

Subject-Obstetrics & Gynecology

SUBMITTED TO - SUBMITTED BY-

Mrs. ANNAMMA SUMON PRIYANKA
GEHLOT
NURSING LECTURE M.sc (N) Previous year
GCON, Jodhpur 2019