NATIONAL ACADEMY OF MEDICAL SCIENCES

BIR HOSPITAL NURSING CAMPUS

MAHABOUDHA, KATHMANDU

Report On “Antenatal Examination”

Submitted To Submitted by
Ms. Anita Maharjan Akshyata Pandey
Ms. Priya Thapa Roll No. 1
Hospital Nursing Administrator Bsc. Nursing 3rd year
BHNC, NAMS BHNC, NAMS

Submitted On: 2080/12/4

ANTENATAL EXAMINATION:
Introduction:
The examination during antenatal period provides an opportunity to have detail assessment of
women give information of the importance about skilled birth attendant during delivery, inform
women and her family about danger signs of pregnancy, delivery and postpartum period focusing
on birth spacing and family planning.
The examination of a pregnant women to determine the normalcy of fetal growth in relation to the
gestational age, position of the fetus in uterus and its relationship to the maternal pelvis is called
antenatal assessment.

Purposes/Objectives of antenatal examination

• To identify and monitor the condition of the women and the fetus.
• To screen the “high-risk” cases of pregnancy.
• To ensure alive, healthy and normal baby.
• To identify the social, economic and educational status of the women
• To assess the possible complications related to pregnancy and minimize those by proper
medical interventions.
• To detect the complications of pregnancy at an early stage.
• The main objective is to ensure a normal pregnancy with delivery of a healthy baby from
healthy mother.
• To support and provide education regarding pregnancy, child birth and post-natal period
including focusing on self-care, help to identify danger signs and seek for medical help.

Equipments needed for Antenatal Examination

1. Weighing machine
2. Height scale
3. BP set
4. Thermometer
5. Measuring tape
6. Watch
7. Torch light
8. Doppler, Fetoscope
9. Sterile gloves
10. Screen
11. Registration logbook
12. Bucket for waste disposal
13. Examination bed, chair, table
14. Handwashing supplies
 15. Sanitizer
16. USG gel

A. HISTORY TAKING
1. Demographic Data:
Name: Mrs. Nepali
Age:28 years
Religion: Hindu
Marital Status: Married
Duration of marriage: 2 years
Education: Class 10
Occupation: Homemaker
Occupation of husband: Labor worker in Kuwait
Education of Husband: Class 10
Address: Gongabu, Kathmandu
Height: 5feet 1 inch
Weight: 65.3 kg
Gravida: 1
Parity : 0
Date of first ANC examination: Asoj 17

2. Chief Complain:
Not any specific complaints

3. Menstrual History
Age of menarche: 14 years
Duration and amount: 3 days with normal amount
Regularity: Irregular initially for 6 years following menarche
Regular after 20 years of age
Pain: Minimal to no pain
 LMP: 2080/3/5

4. Obstetric History
a. Past obstetric history – Woman is a primigravida.
b.Present obstetric history:
▪ Gravida: primigravida, G1
▪ Parity: nulliparous, P0
▪ Last Menstrual Period (LMP): 2080/3/5
▪ Expected Date of Delivery (EDD): 2080/12/12
▪ Week of Gestation (WOG): 38 weeks 2 days
▪ Date of quickening: 17 weeks of gestation
▪ Date of ANC visit: 2080/12/1

5. Past medical history and surgical history: Not any

6. Family health history: Women’s mother has hypertension since 13 years and her father has
diabetes mellitus type 2 since 4 years
7. Personal health habits

• Smoking: non-smoker
• Alcohol usage: occasional social drinker,
• Dietary habits: Likes having chocolates
No any food allergies and specific food dislikes
• Rest/Sleep: Does not nap during the day
5-6 hours of sleep at night

• Elimination Habits: Stress incontinence while coughing in 2nd trimester,

Regular bowel and bladder history with normal amount,
consistency and color.
Bowel slightly greenish with intake of green leafy vegetables

• Drug abuse: None

8. Treatment history

• History of any previous hospital admission: None

• Blood transfusion: Not till date
• Allergy to any drugs: None
• History of immunization against tetanus: 2 doses of TD at interval of 4 weeks

9. Contraceptive history

• Type of contraceptive devices used: None

10. Socio-economic history

• Employment/type of occupation: Worked as waitress pre-pregancy

• Home circumstances: Lives alone
• Financial condition: Moderate, sufficient
• Domestic violence: Women’s husband is abroad and her in-laws are also back in
their hometown, so no any history of domestic violence is relevant
• Marital Status (current relationship with partner): Married for 2 years, used to live
in Kuwait with her husband, returned back to Nepal after being aware of her
pregnancy.

I l. Lab investigation:
2080/7/13 : Hemoglobin (Hb) - 12.7 gm/dl
Blood group – A +ve
Serology (VDRL, HBsAg, HIV1, HIV2) – Non-reactive
Urine (Albumin/Sugar)- Nil
Random Blood Sugar (RBS)- 91 mg/dl
2080/9/14 : GCT : 101 mg/dl
2080/10/25 : USG findings:
Singleton fetus with cephalic presentation
Anterior wall placenta
EFW approximately 1985 gm
35 weeks 2 days gestational age
B. PHYSICAL EXAMINATION
1. General appearance:
• Gait and movement – normal gait, no limping movement
• Facial Expression - smiling
• General cleanliness – Hygiene was maintained
2. Measurements:
• Blood pressure – 100/70 mmHg
• Weight – 63.5 kg
• Height – 5 feet 1 inch
3. Head to toe examination
a. Eye: pallor and icterus absent
b. Ears: absence of any discharges,
c. Nose: patent airway,
d. Mouth: Pinkish gums, tongue and mucous membrane
Dental carries in 2nd molar teeth on left side
e. Neck: No tenderness and enlargement of thyroid gland
f. Breast: symmetrical, striae was not present
No abnormal secretions from nipples, absence of crack, depression on nipples
g. Chest: Normal breathing pattern, respiration rate = 23 breaths/min
h. Abdomen:
On inspection: Uterus is longitudinal, normal term sized uterus
Straie gravidarum, sores and surgical scars was absent
Linea nigra is present
Fetal movement is present

On palpation: Fundal-symphysis height is 36.5 cm.

Obstetric grip/Leopold’s maneuver
a. Fundal grip : Fetal buttocks occupies the fundal part of the uterus,
Longitudinal lie
The lower pole of uterus occupied by fetal head
b. Lateral grip : Fetal back situated on the right side of the woman’s
abdomen (ROA- Right Occiput Anterior)
 c. Pelvic grip : The presenting part is vertex, Fetal head was not engaged,
on the pelvic brim (4/5)
d. Pawlik grip : Fetal head was not engaged, on the pelvic brim (4/5)

On auscultation : Fetal Heart Sound (FHS) was 152 b/min

i. Genitalia : No any abnormal discharge and bleeding from vagina and absence of
abnormalities as stated by the woman.
j. Legs: Tibial and ankle edema was not present.
Varicose veins were absent.

PROCEDURE:
• Woman was greeted and the procedure was explained in brief. Consent was obtained and
the woman was made assured about her privacy and confidentiality.
• All the necessary equipment needed for antenatal examination was assembled.
• Complete personal, social, gynecological history including social support were collected
and recorded.
• Complete medical, surgical and family history was taken including past and present
obstetric history along with contraceptive history.
• Woman was asked to void before the examination.
• Proper hand hygiene was maintained before examination and the mother’s general
condition was assessed. She was well groomed, gait was normal and appeared to be in a
happy mood. Her facial expressions were congruent, periorbital swelling was absent with
no signs of anemia and jaundice in the palpebral conjunctiva and bulbar conjunctiva
respectively.
• Eyes, nose, ears, mouth and tongue were normal and women had no complaints with her
vision and hearing. No any specific cravings, likes and dislikes were verbalized by the
woman.
• Both breasts were normal in size, shape with dark pigmentation on areola, no abnormalities
of nipple, masses, lumps, and abnormal secretions were also absent as stated by woman.
• Abdominal examination was done by inspection, palpation and auscultation. Leopold’s
maneuver was used for identifying the presentation, lie and position of the baby in relation
to maternal pelvis.
• Tibial and ankle edema was not present. Varicose veins were absent.
• No any abnormal discharge and bleeding from vagina and absence of abnormalities as
stated by the woman.
Throughout the procedure, communication was maintained with the woman and consent was taken
step-wise while she coordinated well with the examination. Findings of the examination was
explained and the queries were addressed. Then,
• Woman was kept in a comfortable position and was provided counseling and health
teaching regarding BPCR (Birth Preparedness and Complication Readiness), hygiene,
nutrition, exercise, signs of true labor pain, danger signs, continuation of Iron and Calcium
supplements, PMTCT counseling.
• Follow up date and time was provided to the woman with the instruction to repeat USG
according to the doctor’s prescription.
• Proper recording and reporting was done.
• All the articles were replaced and handwashing was done after the procedure.

IMPRESSION:
There were normal findings of antenatal examination and all the necessary health teaching and
counseling was provided to the woman.