Antenatal care

 ANC is the complex of interventions that a pregnant woman receives; so as to have safe
pregnancy, safe delivery and healthy baby
 is the care given to pregnant women so that she will have safe pregnancy and healthy baby.
(A holistic care (service) given to a women from the date of conception to date of birth of
the child.)
 It is comprehensive health supervision of pregnant women before delivery or it is planned
examination, observation, and guidance given to pregnant women from conception till the
time of labor.
 It is the clinical examination, observation, and follow up of the mother and fetus during
pregnancy, for the purpose of obtaining the best possible health for the mother and child.

 Goals of Ante natal care

The main goal is the safety and welfare of the mother and her fetus.
To reduce maternal and perinatal mortality and morbidity rate
To improve the physical and mental health of women and children
To prepare the women for labor, lactation, and care of her infant
To detect early and treat properly complicated conditions that could endanger the life or
impair the health of mother or the fetus.
It aims to prevent, identify, and ameliorate maternal and fetal abnormality that can adversely
affect pregnancy outcome.
Prevention of complication and disease, health promotion
To prepare the mother physically & emotional for labour and breast feeding and for
subsequent care of the baby.
To select the high risk mother for hospital delivery.
To give health education about immunization, personal hygiene, nutrition, place of
delivery, breast feeding, and family planning.
Birth preparedness and complication readiness
N.B. Antenatal care is a corner stone of obstetrics.

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Models of ANC
• Traditional or standard (western) model
• The WHO ANC model: the new & current model
Models of ANC
• Traditional or standard (western) model
• The WHO ANC model: the new & current model
Traditional or standard model

• Recommends the 1 st visit to take place as early as the first missed period
• The approach is risk based
• This allow accurate dating of the pregnancy & design appropriate preventive and
therapeutic intervention(s)
• Subsequent visit are planned:
Every 4 week until 28 weeks
Every 2 week b/n 28-36 weeks
Every week after 36 weeks
• More frequent visit are required for high risk patient
 Traditional or standard model …
Why Risk Approach Is Not Effective?
Complications cannot be predicted: all pregnant women are at risk.
Risk factors are not usually the direct cause of complications
Many low risk women develop complications
Most high risk women give birth without complications
Focused Antenatal Care (FANC)/ the new WHO ANC model
• An approach to ANC that emphasizes on provision of specific evidence based
interventions for all women
• Having one or more visits with trained person during pregnancy by trained person
can detect early signs of disease or risk factors for timely intervention(WHO)

The new WHO ANC model emphasizes on:

 Individualized care

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  Client centered care
 Fewer but comprehensive visits
 Disease detection not risk classification
 Care by a skilled provider
 FANC emphasizes quality care rather than the quantity.
 For normal pregnancies WHO recommends only four antenatal visits
The new WHO ANC model…
Recommend a minimum of four visits
– First <16 weeks / lasts for 30-40 minutes/
– Second 24-28 wks / lasts for 20 minutes/
– Third 30-32 wks / lasts for 20 minutes/
– Fourth 36-40 wks / lasts for 20 minutes/

N.B* When a woman has complication. :e.g.: - raised BP – she should attend weekly.
It means good clinical decisions must be made at each visit
• The Focused ANC Model: classifying care
• Focused antenatal care groups pregnant women in to two groups based on their specific
health conditions or risk factors:
 Those legible to receive routine ANC called basic component
 Those who need special care
Those having problem would not be eligible for the basic component of the WHO
antenatal care model, rather should receive care corresponding to the detected condition.

The Focused ANC Model: classifying care

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Yes Specialized care, additional
evaluation /assessment or
follow-up, if needed in
clinic or elsewhere
 risk factors
All women detected in
First visit Classifying applying the
form classifying form Transfer of patients
between the basic
component and
specialized care is
possible throughout
ANC
No
Basic component of
Focused ANC
component

Components of FANC:
• The major goal of focused antenatal care is to help women maintain normal pregnancies
by providing important health services under the following components of FANC:
– Identification of pre-existing health conditions
– Early detection of complications arising during the pregnancy
– Health promotion and disease prevention
– Birth preparedness and complication readiness planning.
Identification of Pre-existing health conditions such as
• HIV, malaria, syphilis and other STIs, anemia, heart disease, diabetes, malnutrition, and
tuberculosis may affect the outcome of pregnancy, require
• Immediate treatment, and usually require a more intensive level of monitoring and
follow-up care over the course of pregnancy.
Early Detection of Complications:
• The provider talks with and examines the woman to detect problems of pregnancy that
might need treatment and closer monitoring.
• Conditions such as anemia, infection, vaginal bleeding, hypertensive disorders of

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 pregnancy, and abnormal fetal growth or abnormal fetal position after 36 weeks may be
or become life-threatening if left untreated.
Health Promotion and Disease Prevention
Counsel the woman:
• How to recognize danger signs, what to do, and where to get help
• Good nutrition and the importance of rest
• Hygiene and infection prevention practices
• Risks of using tobacco, alcohol, local drugs, and traditional remedies
• Breastfeeding
• Postpartum family planning and birth spacing.
• Counseling on family planning
• female sterilization; within 2 days - 6 weeks, if no sign of infection
• IUD (48 hours-4 weeks after delivery if no infection)
• options for lactating mother:
 Immediately postpartum: (LAM), Condoms, Spermicide, Female sterilizatio, IUD
 Delay 6 weeks: POP, Progestrogen-only injectables, Implants
 Delay 6 months: COC, combined injectable, Fertility awareness methods
Providing preventive services
• All pregnant women should receive the following preventive interventions:
– Iron and folate supplementation
• To all pregnant, postpartum and post-abortion women
Routinely 60mg elemental iron and 400 μg folic acid once daily in pregnancy and until
3 months after delivery or abortion.
• Twice daily as treatment for anaemia (double dose).
Give tetanus toxoid
• In areas of high prevalence of hookworms, women should also receive
De-worming
• To prevent 41 - 56% of moderate to severe anemia.
• Give mebendazole 500 mg once in second or third trimester to every woman in
hookworm endemic areas.
 counseling and testing for HIV

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  Protection against malaria through intermittent preventive treatment and insecticide-treated
bed nets
 Protection against vitamin A and iodine deficiencies
Birth Preparedness and Complication Readiness
It is the process of planning for normal birth and anticipating the actions needed in case of an
emergency; so a woman should have plan for:
• Facility or place of birth
• Transportation
• Funds
• Support person
• Decision maker
• Blood donor
• Danger signs in labour
• A skilled attendant at birth
• The place of birth and how to get there including how to obtain emergency transportation if
needed
• Items needed for the birth
• Money saved to pay the skilled provider and for any needed medications and supplies
• Support during and after the birth (e.g., family, friends)
• Potential blood donors in case of emergency.

Advise on danger signs

• Vaginal bleeding.
• Convulsions.
• Severe headaches with blurred vision.
• Fever and too weak to get out of bed.
• Severe abdominal pain.
• Fast or difficult breathing
Discuss how to prepare for an emergency in pregnancy
Advice and counsel on family planning
Counseling during pregnancy

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Advise on routine and follow-up visits
– 1st visit Before 4 months Before 16 weeks
– 2nd visit 6 months 24-28 weeks
– 3rd visit 8 months 30-32 weeks
– 4th visit 9 months 36-38 weeks
Taking history of pregnant mother
Booking Visit/ initial visit/
Should take place as soon as possible after pregnancy has been confirmed, b/s it helps to give early
advice on maternal nutrition, prevention of infection, smoking or drug taking, alcohol . . . because
all these may have a profound effect on the fetus before the fetal organs are not completely formed.
(Fetal organs almost completely formed by 12th weeks of pregnancy.)
Objectives of the booking visit
-To assess level of health by taking a detailed history and to employ screening tests.
-To ascertain base line recordings in order to assess normality & also used for comparison the
pregnancy progresses.
-To asses general medical status of women identify risk factors
-To provide an opportunity for the woman & her family to express any concerns.

-To give advice on general health matter, in order to maintain the health of the mother and

healthy fetal development.

- To look in to new developments, therefore, subsequent visits take much shorter time

Activities on the first visit

 Registration, History taking, weight measurement, Physical examination, Laboratory

investigation, Management of compliant, Prophylaxis, Immunization, Health education
 The first FANC visit should ideally occur before 16 weeks of pregnancy. You are expected
to achieve the following objectives:
 Determine the woman’s medical and obstetric history in order to collect evidence of her
eligibility to follow the basic component of FANC, or determine if she needs special care
and/or referral to a higher health facility.
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  Perform basic examinations (pulse rate, blood pressure, respiration rate, temperature,
pallor, etc.). If you think the pregnancy is beyond the first trimester, try to determine the
gestational age of the fetus by measuring fundal height.
 Provide nutritional advice and routine iron and folate supplementation.
 Advising against misconceptions about diet is also important. For example, in some parts of
Ethiopia it is thought that eating eggs and meat during pregnancy will cause vernix (the
sticky white substance on the baby’s skin at birth), and that vernix is dirty. In fact, eggs and
meat
are important sources of protein for the mother and the developing fetus, and vernix is good
for the baby because it protects the baby’s skin.
 Provide HIV counselling and PMTCT services
 Give advice on malaria prevention and if necessary provide insecticide-treated bed nets
(ITNs).
 Check her urine for sugar using the dipstick test, or refer her to the health facility if you
suspect she may be developing diabetes.
 Advise her and her partner to save money in case you need to refer her, especially if there is
an emergency requiring transport to a health facility. She may also need money for
additional drugs and treatments. Financial help may be available from local community
organizations like women’s groups.
 Provide specific answers to the woman’s questions or concerns, or those of her partner.
if there is a difference of several weeks between the gestational age estimated from fundal
height measurement and the estimate based on last normal menstrual period (LNMP)?
 This may mean that the woman has not remembered the date of her LMNP correctly, but it
could also mean that the fetus is not growing normally (fundal height lower than LNMP
estimate), or there could be too much amniotic fluid around the fetus, or a twin pregnancy
or very big baby (fundal height larger than LNMP estimate).

The second FANC visit

 Schedule the second FANC visit at 24-28 weeks of pregnancy. Follow the procedures
already described for the first visit. In addition:

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  Address any complaints and concerns of the pregnant woman hypertension and her
partner.
 For first-time mothers and anyone with a history of or pre-eclampsia/eclampsia),
perform the dipstick test for protein in the urine.
 Review and if necessary modify her individualized care plan.
 Give advice on any sources of social or financial support that may be available in her
community.
The third FANC visit
 The third FANC visit should take place around 30–32 weeks of gestation. The
objectives of the third visit are the same as those of the second visit. In addition
you should:
 Direct special attention toward signs of multiple pregnancies and refer her if
you suspect there is more than one fetus.
 Review the birth preparedness and the complication readiness plan.
 Perform the dipstick test for protein in the urine for all pregnant women (since
hypertensive disorders of pregnancy are unpredictable and late pregnancy
phenomena).
 Decide on the need for referral based on your updated risk assessment.
 Give advice on family planning.
 Encourage the woman to consider exclusive breastfeeding for her baby
 Remember that some women will go into labour before the next scheduled
visit. Advise all women to call you at once, or come to you, as soon as they go
into labour. Don’t wait!
 Emphasize the importance of the first postnatal visit to ensure that the woman
is seen
 The most critical postnatal period for the mother is the first 4 hours; this is
when most cases of postpartum hemorrhage (PPH) occur.

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The fourth FANC visit
 The fourth FANC visit should be the final one for women in the basic
component and should occur between weeks 36-40 of gestation. You should
cover all the activities already described for the third visit. In addition:
 The abdominal examination should confirm fetal lie and presentation.
 At this visit, it is extremely important that you discover women with a baby in
breech presentation or a transverse lie and refer her to the nearest health facility
for obstetric evaluation.
 The individualized birth plan should be reviewed to check that it covers all
aspects of birth preparedness, complication readiness and emergency planning
 Provide the woman with advice on signs of normal labour and pregnancy
related emergencies and how to deal with them, including where she should go
for assistance

DEFINITION OF TERMS
FETO – PELVIC RELATION SHIP

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 • MECHANISM - Series of movements of the fetus in his passage through the birth canal.
• LIE - Relationship between the long axis of the fetus and the long axis of the mother’s
uterus.
• ATTITUDE - Relationship of the fetal parts to one another.
• Normal  flexion.
• Abnormal  Extension.
PRESENTATION
the part of the fetus which lies in the lower pole of the uterus.
• Normal  Vertex 96. 8%
• Abnormal  breech 2.5%
 Shoulder 4% (1 in 250)
 Face 0.2% (1 in 500)
 Brow 0.1% (1 in 1000)
• PRESENTING PART - The part of the fetus coming first and felt on vaginalexamination.
• POSITION – Relationship of the denominator to the six areas of the mother’s pelvis.
• Normal anterior or lateral.
• Abnormal  Posterior ( malposition). 
• DENOMINATOR – The part of the fetus which tells the position
• In vertex  Occiput.
• In breech  Sacrum.
• In face  Mentum.
• In shoulder  Acromion process.
• In brow  No denominator is used.
• ENGAGED - when the bi – parietal pass the pelvic brim.
• CROWNED - when the bi – parietals pass the ischial spines and the head no longer recedes
between contractions.
• GRAVIDITY - Pregnancy
• GRAVIDA - A pregnant women.
• Primigravida - A woman pregnant for the first time.
• Multigravida - A woman who has had two or more pregnancies.

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 • PARA - A woman who has produced a viable infant (28 wks of gestation) regardless of the
outcome.
• Nullipara - a woman who has not given birth to a child.
• Primipara – a woman who has given birth to one child only.
• Multipara - a woman who has given birth to more than one child.
• Grandmultipara - A woman who has given birth to 5 or more children.
Examples
• A woman with 2 abortion and 2 deliveries are  G IV P II abortion II .
• A woman with 1 abortion, 3 deliveries and 2 stillbirth are  G VI P V abortion I
• A woman with 1 abortion and no alive children are  G I P 0. Abortion I.
• A pregnant woman with one abortion, 2 still birth, and two deliveries are  G VI P IV
abortion I.
Taking history of pregnant mother
Booking Visit
Should take place as soon as possible after pregnancy has been confirmed, b/s it helps to give early
advice on maternal nutrition, infection smoking or drug taking, alcohol . . . because all these may
have a profound effect on the fetus before the fetal organs are not completely formed. (Fetal organs
almost completely formed by 12th weeks of pregnancy.)  
Objectives of the booking visit
-To assess level of health by taking a detailed history and to employ screening tests.
-To ascertain base line recordings in order to assess normality & also used for comparison the
pregnancy progresses.
-To asses general medical status of women identify risk factors
-To provide an opportunity for the woman & her family to express any concerns.
-To give advice on general health matter, in order to maintain the health of the mother and
healthy fetal development.
To look in to new developments, therefore, subsequent visits take much shorter time

Activities on the first visit

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  Registration, History taking, weight measurement, Physical examination, Laboratory
investigation, Management of compliant, Prophylaxis, Immunization, Health education 
Types of health history:
Social history, Medical history, surgical history, Family history, past obstetric history,
present obstetric history ,gynecological hhistory 
Obstetric History
- The midwife requires many skills to get detailed and accurate history such as
communication skill and listening skills. She also must be able to analyses the
information.
- The MW should be patience, tacticful and very kind.
- A midwife can gain much from observing a woman as she is invited into the interview room.
Observation of physical characteristics is also important. Posture and gait can indicate back
problems or previous trauma to the pelvis. Before starting interview the midwife should greet the
mother & makes sure the mother is sitting comfortable.

Identification
• Name
• Age (significant if <20 yr and >35 yr )
• Marital status
• Address – far distance from the health institution

Chief compliant
• The client may come for routine ANC follow up or may come with one or more
specific compliant
• Note the duration of each compliant

History of pregnancy
• Gravidity: all forms of pregnancy whether it is term, live births, still birth, abortion,
ectopic pregnancy or molar pregnancy
• Parity: fetus delivered after 28 weeks of gestation for Ethiopia & UK, and > 20 weeks
according to WHO
• Abortion
• The normal last menstrual period & the regularity of periods.

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 • Any abnormality during this pregnancy
• Last menstrual period /LMP/ the first date of the last menstrual cycle is important to
calculate Expected date of delivery (EDD) and Gestational age (GA)
Expected date of delivery (EDD): The calculated date for the birth of the fetus.
Gestational age: Estimated age of the fetus calculated in weeks from the first day of the
last menstrual period.
- Calculate gestational age at any point in pregnancy.
- This helps to compare the actual fetal size with expected size.

Ethiopian calendar

 LNMP + 9 month + 10 days (if pagume is not passed)

 LNMP +9 month + 5 days/ 4 days in leap year (if pagume is passed) this method assumes
that: Conception occurred 14 days after the first day of the LMP
The last period of bleeding was true menstruation.
• Calculate gestational age in completed week &/or days
• Quickening : used to date pregnancy if LNMP is unknown
• Presence of ANC elsewhere
• Elaboration of chief complaint
• Danger symptom of pregnancy

Danger symptoms of pregnancy are:

 Vaginal bleeding
 Profuse vaginal discharge
 Epigastria or severe abdominal pain
 Severe head ache
 Blurring of vision
 Fever
 Persistent vomiting
 Absence or reduction fetal mov’t
 Common compliant during pregnancy
 Pregnancy:-unplanned, unwanted or unsupported
 

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Social History
This includes: Mother’s name, Age, Address, Occupation, Marital status
Education level, Religion
Medical History
Medical conditions affect the pregnancy. So the mother should be asked if she has had any
medical disease such as - Pulmonary tuberculosis (PTBC), Hypertension, Heart disease,
renal disease, Diabetes, Asthma, Epilepsy, Anemia, STDs, Psychiatric disorders 
Surgical history Ask for any, operation, blood transfusion, Accidents, Cervical cerclage
 
Family history
Certain conditions are genetic in origin, others are familiar or racial characteristics & some
may occur b/s of the social environment in which the family lives.
Hypertension, Diabetes, Psychiatric disorder, Twins, TB & contagious diseases
Past obstetric History

Ask about previous pregnancy in chronological order

• Date, month, & year of gestation e.g. first delivery in May 2000 E.C
• Length of gestation: abortion(< 28 weeks), preterm(<37 completed weeks), term (>37
weeks to 42 completed weeks)
• Significant antenatal medical problem like HTN, ante partum hemorrhage and diabetes
• Onset of labor (spontaneous or induced)
• Still birth & neonatal death, Place of delivery, Type of delivery
The length or duration of labour, Baby weight, Preterm birth (delivery), Post term birth
(delivery), Ante or post partum hemorrhage, Puerperal infection, Family planning use,
• Tetanus toxoid (TT) vaccine., Congenital abnormalities
• Fetal presentation
• Duration of labor
• Mode of delivery (spontaneous vaginal, instrumental, C/S, destructive delivery)
• Fetal outcome (alive or dead, sex of the new born, wt. of the new born, malformation
& current condition)
• Post partum complication such as PPH

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 • Breast feeding

Gynecology History
• FP method : use, type, duration & side effect (SE)
• Sexual history: assess risk of STI & HIV/AIDS
• Gynecology operations: FGM, laparatomy, dilatation & curettage, evacuation and
curettage and manual vacuum aspiration (MVA)

• Menstrual history ( age of menarche, interval of period 21-36 days, amount of flow
(10-81ml), duration of flow(1-8 day), normally dark red and non-clotting)

Past medical & surgical history

• Hx of DM, HTN, hypo & hyper thyroidism : this may affect pregnancy or aggravated
by pregnancy
• Blood transfusion: important in hemolytic disease of new born
• Drug b/c of risk of teratogenicity or allergic reactions
• Maternal infection: TORCH syndrome

Personal, family and social history

• Childhood development
• Educational status
• Habit like alcohol, smoking, and elicit drug
• Occupation:- exposure to radiation, anesthesia( haloethen), chemical factory and other
• Income- low soci-economic status associated with obstetrics problem like
preeclampsia, preterm
• Family Hx: DM, HTN, multiple pregnancy, genetic disorder
•
 Class work. If you are a clinician and a 26 years ladies come your clinic with LMP
30/7/06 E.C and visiting day also 19/12/06 E.C. what is the GA of the mothers?

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Bio graphic dx (social hx)
Name___ Age___ address ___occupational status __marital status___
LMP____GA___ EDD___Para ____ gravida _____

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Physical examination for pregnant woman

Points to consider before & /or during &/ or after examination

• Examination must be done in a private room in the presence of assistant preferably
female
• Proper explanation must be offered to the patient before, during & after the
examination
• Bladder should be emptied
• The client properly positioned on the couch
• Warm hands & instruments must be used
• Adequate light, appropriate gloves and swabs should be prepared
• Always keep eye contact throughout the examination
Equipment
• V/S equipment
• Large towel to cover
• Stair (ደረጃ)
• Screen (if needed)
• Fetoscope
• Alcohol swab to clean fetoscope
• Clean glove
• Bed pan (if needed)
• One receiver
• Request paper
• Wt and Ht Scale
• 3 lab paper
• U/A
• Blood
• Stool
• Ultrasound
• Chair for nurse and women
• Simulated tablets (SP)
• 0.5% chlorine solution and receptacle for decontamination

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 • Learning Guide for Antenatal Care
• Checklist for Antenatal Care

General appearance: well or sick looking

The nurse should observe the general appearance of the mother (any deformity)

Vital sign & anthropometric measurements

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 Blood pressure/BP/ - BP positions include left lateral with 30 tilt to the left to avoid
supine hypotensive syndrome or sitting position in ambulatory position
It should be checked and recorded at each visit, it may be falsely elevated if a woman is
nervous or anxious, exercise.
 Height-less than 150 cm height and shoes size less than 35 indicate small size pelvis could
be constitutional but may be a risk factor.
 Height should be checked at the first visit.
 Weight-total weight gain should not exceed 12.5 kg
Obesity can lead to an increase risk of gestational diabetes and pregnancy induced
hypertension (PIH). To be accurate, weight should always be measured using the same
scale & the woman asked to wear similar clothing at each visit.
 Pulse rate : increases 10-15 beat/ minute in pregnancy
 RR: increase in 1-4 breath/ minute in pregnancy
 Temperature

Physical examination should be done from the head up to toe

HEENT
Head -observe the hair for its cleanliness and health.
Face -observe for skin change (chloasma)
Ears -ask for any discharge or pain & observe it.
Eyes -observe the sclera for jaundice (yellow) and conjunctiva for paleness (anemia)
Mouth and tongue
Observe for dryness or moist and how is the gum and teeth for any bleeding & decayed teeth.
Lymphoglandular system
Neck -Observe and palpate for any swollen gland & lymph node. (Thyroid glands)

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Axilla -Palpate for swollen lymph node.
Breast examination
-Ask permission before starting the examination.
-Observe changes due to pregnancy & nipples condition, are they inverted or flat?
- Check the symmetry
-Palpate to feel any lump (mass)
Procedure
-Divide the breast into four quadrants with imaginary line.
 Using the flat of the hands cover two opposite quadrants of the breast & palpate the breast
against chest wall, then the rest two quadrant should palpate the same way.
-Express colostrum (The nipple should be drawn forward to see if it is protractile).
- Check nipple & role the nipple with the thumb and the fore finger.
-Advice mother to do this in her home (If she is primigravida with flat nipple) but do not pull
the nipple.
 
Respiratory system
Inspection - count the RR/m 16 – 20/m
- Rhythm - regular
- Irregular
- Observe respiratory diseases
 nasal flaring
 abnormal sounds (wheezing)
 cyanosis
Palpation -Total lung expansion - symmetrical
-Tenderness

Cardiovascular system
Inspection
Inspect for point of maximum impulse (PMI)
Left fifth inter costal space in the mid clavicular line then palpate it) deviation to left is possible in
pregnancy.

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 th
Palpation of the PMI in two or more adjacent intercostals spaces, below 5 is or lateral to MCL
indicate cardiac enlargement. 
Auscultation
- Heart sounds S and S (lub – dub)
1 2
-S -created by closure of mitral & tricuspid valves.
1
-S - created by closure of aortic & pulmonary valve
2
Abdominal examination
Aim of abdominal examination
-To observe signs of pregnancy
-To assess fetal size & growth
-To diagnose the location of fetal part
-To detect any deviation from normal
Preparation
 Her bladder should be empty with in30 minutes before abdominal examination, this helps
comfort and accurate measurement of fundal height
 In general examination will have been conducted with the mother sitting or standing but
during the abdominal exam, she must lie on the couch with her arms by her sides.
 Privacy is important during abdominal examination

Methods
Inspection, Palpation, Auscultation
A. Inspection
Note 5 “s”: - Shape, Size, Skin changes, Scare, Striae
1.The size of the uterus: - is assessed roughly by eye. Should correspond with the supposed period
of gestation A distended colon or obesity may give a false impression of size multiple pregnancy or
polyhydramnious will enlarge both the length & breadth of the uterus where as a large baby
increases only the length.
2.Shape of the uterus: - is longer than it is broad when the lie of the fetus is longitudinal. If the lie
of the fetus is transverse the uterus is low & broad.

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 Usually in primigravida the shape is oval
In OPP/posterior position of the occiput/ a saucer like depression is seen at or below the
umbilicus.
3.Fetal movement: - is evidence of fetal life and aids in the diagnosis of position.
4.Contour of the abdominal wall: - a full bladder may be visible & is more obvious in later wks.
The umbilicus becomes less dimple as pregnancy advance, may protrude slightly in later
weeks.
When the woman is erect, lightering may be evident.
Lax abdominal muscles of the multiparous woman may allow the uterus to sag forwards
=>pendulous abdomen.
In primigravida it is a serious sign (May due to CPD).
5.Skin change: - the condition of the skin is observed about rash, lineanigra & striaegravidrum.
6.Scares: - may indicate previous obstetric or abdominal surgery
B. Palpation of the abdomen
The hand should be clean and warm
Cold hands induce contraction & cause discomfort.
Arms and hands should be relaxed and the pads not the tips, of the fingers used with delicate
precision. 
Types : - Superficial palpation: check for rigidity, tenderness, superficial mass & characterize it
any abdominal defect
-Deep palpation: palpate for mass, organomegally, & characterize the mass
-Obstetric palpation or leopold’s maneuver

The 1st Leopold’s Manoevures( Fundal Palpation)

1. Fundal height (FH) measurement use one of the following two methods
Finger method: one finger above umbilicus is equal to two weeks and below umbilicus one
finger is equal to one week
Using a tape measure.
The height of the fundus correlates well with gestational age, especially during the earlier
wks of pregnancy. After 20 weeks FH in cm is approximately equal to G.A inweeks

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  At 12 to 14 weeks of pregnancy, the uterus is palpated above the
symphysis pubis
 At 20 to 22 weeks :- at the umbilicus
 At 36 weeks:- at xiyphoid process, and
 often returns to about 4 cm below the xiyphiod due to “lightening” at 40
weeks

This helps to estimate the period of gestation (G.A). This method does not always produce an
accurate result because the size and number of fetus and the amount of amniotic fluid, maternal size
and parity may also affect the estimation.
Procedure:
Stand on the right side of the woman’s bed facing the woman.
Warm your hands & place just below xiphisternum, pressing gently and move your hands down the
abdomen until you feel the curved upper border of the fundus.
 Note the number of finger breadths or measure the distance of the fundus from the
symphysis pubis
 If the uterus is unduly big, the fetus may be large, multiple pregnancy or polyhydramnious
may be suspected.
 When the uterus is smaller than expected, may the women mistaken in the date of her LMP,
IUGR &oligohydraminous suspected. Also lower fundal height indicate abnormal fetal
presentation & anomalies

Fundal palpation
 In order to determine whether the fundus contains the breech or the head. 
This information will help to diagnoses the lie and presentation.
Procedure:
 place both hands on the sides of the fundus, fingers held close together and curving round
the upper border of the uterus.
 Gentle pressure is applied using the palmar surface of the fingers to determine the soft
consistency & indefinite outline that denotes the breech, if the breech in the fundus you will
feel large and soft parts and it can not move freely.

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  If the head is in the fundus you will feel a hard & round part& it can moved
independently, can be balloted b/n the fingertips of the two hands.
 If the lie of the fetus is longitudinal, the uterus will be longer than its broad, if the lie of the
fetus is transverse, the uterus will be broader

2. Lateral palpation Determine what occupies the fundus.

I. Determine the lie of the fetus w/h could be longitudinal, transverse, or oblique
II. In longitudinal lie, it determines on w/h side of the abdomen is the fetal back.
Procedure
The hands placed on either side of the uterus at about umbilical level.
Steady the uterus with one hand and the opposite hand palpate the side of abdomen using a rotary
movement. The same movements should be repeated on the other side. This helps to detect which
side of the uterus offers the greater resistance.
* The back is felt as a curve smooth resistant mass
* The limbs felt as small irregular parts and bulky masses.
 The FHB is best heard on back side
 Always face toward the mother.

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3. Deep pelvic Palpation: (3rd Leopold’s Maneuver)
Palpation of the lower pole of the uterus just above the pelvis.
It helps to diagnose the presentation and engagement of the presenting part and also help to
determine the attitude in vertex presentation.
 In extended attitude, the cephalic prominence is on the same side of the
back
 In flexed attitude, the cephalic prominence is on the opposite side of the
back
Procedure
 Ask the woman to bend her knees slightly in order to relax the abdominal muscles.
 Turn your body to face the mother’s feet.
 Grasp the uterus below umbilical level b/n the palms of the hand with fingers,
 Held close together, pointing downwards and inwards.
 If the head is presenting, a hard mass with a distinctive round, smooth surface will be
felt.
 In order to determine if the vertex is presenting, the occipital and sincipital prominences
are located.

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  If the head is well flexed the sinciput will be felt on the opposite side from the back and
higher than the occiput.
 If the head is deflexed the prominences are on the same level.
 If the head is extended as in a face presentation the bulk of the head is felt on the same side
as the back.
 In cephalic presentation, it determines the descent by using the rule of fifth w/h measure the
distance between upper boarder of symphysis to the anterior shoulder

Deep pelvic Palpation

 5/5 is floating head - 2/5 indicate engaged head
 4/5 is fixed head

th
4. Pawlick's Grip: (4 Leopard Maneuver)

It helps to determine the presentation, to judge size, flexion and mobility of the head but the
midwife must be careful not to apply undue pressure.
• The lower pole of the uterus is grasped with the right hand facing toward the women's
head,

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 • Feel the occiput and sinciput, note which is lower.
• It is the only maneuver that is done with one hand
Procedure
Grasp the lower pole of the uterus between the thumb & fingers of one hand.
It should be spread wide enough a part to accommodate the fetal head. 
Turn the face towards the mother

5. Bi-polar grip manoeuver

Feel upper and lower poles together to see which is hard.
Only use when in doubt about presentation.
C. Auscultation
 Auscultation usually forms part of each abdominal examination and follows any procedure
in order to assess fetal wellbeing.
 It measures b/n 120 – 160 beats per minute
 Pinards fetal stethoscope is commonly used to hear the fetal back.
 It can be heard from 20 wks on wards, the fetal heart is heard most clearly over the fetal
back.
 Check Fetal heart, rate and rhythm, count for one minute if regular.
 Use Pinards stethoscope (fetoscope) hand should not touch it while listening,

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 st
 FHB is 1 heard in the back side of fetus at 16-18 wk in multipara & 18-20 wk in
primigravid
 In complet breech presentation , it is heard above umbilicus
 In cephalic presentation, it is below the umbilicus
 In occipito posterior presentation, it is heard in the flanks
 
Procedure
 Place the pinards fetal stethoscope on the mother’s abdomen at the side of fetal back.
 The ear must be in close, firm contact with the stethoscope but the hand should not touch
it while listening because extraneous sounds are produced.
 If the presentation is cephalic, the fetal heart beat heard below the umbilicus.
 But if the presentation is breech, it will be best heard at (above) the level of umbilicus.
 The fetal heart beat will be muffled if the mother’s abdominal wall is thick, as it is in obese
woman or when large amounts of fluid are contained the amniotic sac.
Failure to hear the fetal heart beat may be result from the following reasons
 defective fetoscope
 noisy environment
 early pregnancy
 fetal death( If heard previously)
 obesity
 polyhydramnious
 loud placental soufflé,
 Occipito Posterior Position
Inspection of external genitalia
Scars from episiotomy and perineal lacerations
Vulval varicosities (hemorrhoids)
Genitourinary system
Vaginal discharge
Ask for vaginal discharge, the normal vaginal discharge white in colour, non-offensive and it is not
itchy.
Once the woman has identified what a normal she will then be able to report any changes.

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If the discharge is itchy, causes soreness is any colour other than creamy – white or has an offensive
odour, infection must be suspected & investigated.
In later pregnancy - leucorrhoea changed in to discharge which has colour& consistency of egg
white.
Frequency of micturation is common, The MW should enquire about the presence of any dysuria.
Intgumentary system
• Hyperpigmentation on breast, lower & mid line abdomen
• Vascular change: spider angiomata & palmar erythema
Extremities /musculo – skeletal system/
Observe any deformity of limbs
 Size of feet (<35)
 Check for edema, dilated vessels and calf tenderness

Any oedema

Physiological /Dependent edema ( pretibial, ankle, & pedal) seen in 80% of normal pregnancies

- occurs after rising in the morning and worsens during the day, it associated with daily

activities or hot weather

Pathological edema ( non dependent) involves the face fingers or the whole body associated with
pregnancy – induced hypertension.
Often the woman has noticed that her rings feel tighter and her ankles are swollen.
Test for pitting oedema by applying finger tip pressure for 7 to 10 seconds over tibia bone.
If pitting oedema is present a depression will remain when she removes her finger.
Varicosities
The legs should be examined at every visit. Progesterone relaxed the smooth muscles of the veins
and results in sluggish circulation occur during pregnancy and is a predisposing cause of deep vein
thrombosis.
The valves of the dilated veins become inefficient and varicosities result.
Varicose veins may occur in the legs, anus (haemorrhoids and vulva).
Inspect the leg for varicosities and record their position and condition.
Central nervous system
Laboratory investigation during antenatal care

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 Blood taken at the initial assessment determine
Blood group and
Rhesus (Rh) factor.
Hemoglobin (Hb) - estimations are performed at the initial assessment and repeated at 28 wk.
Venereal Disease Research Laboratory (VDRL) for syphilis. Early testing is important to prevent
infection of the fetus
PICT:- Human immunodeficiency virus (HIV)
Urine - Performed exclude abnormality
- Microscopic for bacteria, culture
- Ketones - ed maternal metabolism
- glucose -diabetic due to higher circulating blood level.
- protein - PIH
- HCT
- HB,C V
- VDRL
- PICT
- Stool – for parasites & If necessary Sputum for - AFB – TB.
Health education:-
 Exercise
 Not lifting heavy loads
 Rest at least 10 hours at night and 2 hours in the afternoon
 Closing, comfortable shoes
 Bathing

 Diet rich in fe, prt, ca02 and vit

 Danger sign of pregnancy
 Vx- bleeding
 Sever frontal headache
 Upper or lower extremity Edema
 Blurred vision
 Excessive Nausea &Vomiting
 Persistent abdominal pain

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  Reduce fetal stage page of fetal mov`t
 Discharge with itching or odor

Iron/folate supplementation
Region/population-specific preventive measures, e.g., malaria prevention
Immunization and Other:-Preventive Measures

Tetanus toxoid immunization

Tetanus Toxoid Immunization Schedule

TT Injection Time for administration Duration of protection

TT 1 At first contact with woman of child bearing No protection

age or as early as possible in pregnancy (at
1st ANC visit)

TT 2 At least 4 weeks after TT 1 Three years

TT 3 At least 6 months after TT 2 Five years

TT 4 At least 1 year after TT 3 Ten years

TT 5 At least 1 year after TT 4 For thirty years

(throughout a women’s
reproductive life)

Iron/folate supplementation:
 To prevent anemia, prescribe: iron 60 mg + folate 400 mcg orally once daily for 3 months
 Dispense supply to last until next visit
 Eat foods rich in vitamin C, which help iron absorption
 Avoid tea, coffee, and colas, which inhibit iron absorption
 Possible side effects of iron/folate – black stools, constipation, and nausea
In areas of endemic disease/deficiency:

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Insecticide-treated nets (ITNs) for malaria – both mother and baby should sleep under one
Presumptive treatment for hookworm infection

Subsequent visits of anc

Hx focus on:-
 New compliant
 Problem since the last visit
 Danger Sm of pregnancy

P/E focuses on:-

 General appearance
 Vital signs mainly the BP
 Weight
 Checking for Sn of anemia
 Other examination based on compliant
 Medication
 Quikning time & fetal mov’t
 Any change in personal Hx
 Fundal Height
 Fetal lie & presentation
 FHB
 Leg edema
 Dipstick of urine for bacteria is done in all visit
 Urine dipstick for protein is only done nulliparous women or for those with history of
preeclampsia or hypertension currently
 Hematocrite is done at the third visit

Scheduling a Return Visit

Advise her to bring her partner or other companion with her if possible
Ensure that she understands that she should not wait for next appointment if she or is having
problems or develops any danger sign
Review maternal and fetus danger signs and complication readiness plan

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