Fakulti Kejururawatan

ANTENATAL CARE : Routine examination &

Abdominal palpation

by

Nor Marini Ibrahim

After the lecture, students should be able
to:

 Explain the aims of prenatal care

 Perform physical examination
 Perform abdominal palpation
 Give health education to pregnant woman
 Tell the type of immunization to pregnant
woman
AIMS OF ANTENATAL CARE:
support & encourage a family’s healthy
psychological adjustment to
childbearing
3. Monitor the progress of pregnancy in
order to ensure maternal health &
normal fetal development
4. Recognise deviation from the normal
& provide management or treatment
as required
5. Ensure that women reaches the end
of their pregnancy physicaly &
emotionally prepared for her delivery
1. Help & support the mother in her
choice of infant feeding to promote
b/feeding & give advice about
preparation for lactation when
appropriate.
2. Build up a trusting relationship
between the family & their caregivers
which will encourage them to
participate in and make informed
choices about the care they receive.
ow chart of Pregnant woman at maternity clin

REGISTRATION

URINE TEST, WEIGHT, HEIGHT MEASUREMENT

& BLOOD PRESURE
HEALTH EDUCATION

BLOOD TEST
Preliminery process by nurse (GRP, Rh., HB & VDRL)

PHYSICAL & ABDOMENT REFER DOCTOR

EXAMINATION, ATT Inj.

ADDMISION/APPOINTMENTI/TREATMEN
1. REGISTRATION/BOOKING A VISIT

- Should be done as soon as the mother

knows that she is pregnant
- Approprite advice should be given early
regarding care for both mother & fetus
because the fetal organs are almost
completely formed by 12 weeks of
pregnancy. Maternal nutrition, infection,
smoking or drug taking
• INTERVIEWING THE ANTENATAL MOTHER
Social history
- name, race, ic no., educational status,
occupation, name of husband, husband’s ic no.,
address & contacting telephone number, date of
marriage
Family history
- any family members suffering from diabetes,
asthma, tuberculosis, hypertension, heart case
Medical & surgical history
- risk factors for human immunodeficiency virus /
acquired immunodeficiency syndrome
(HIV/AIDS), or other sexually transmitted
infection
- Any previous operation esp. involved the
reproductive organ (LSCS)
 Obstetric history
- Number of pregnancy (Gravida)
- Number of living children (para)

- Weeks of pregnancy

- Type & place of delivery

- Other complications (postpartum

hemorrhage), cervical tear, instrumental
delivery etc.
- Menstrual history (regular or not, LMP)

Detail of past & present pregnancy, including

- Miscarriages or abortion

- Outcome of each pregnancy

(team,preterm,stillbirth or baby alive & well)
- Problems in previous pregnancy (PPH,
placenta previa, twin etc)
- Other complication-pre-eclampsia, gdm
 Physical examination
Height
 if 145 cm & below is associated with small
pelvis & may cause cephalo pelvis
dispropotion (CPD)
Weight
 as a baseline weight
 Weight the mother at every visit
 Any weight lost-indicate intra uterine growth
retardation (IUGR) or intra uterine death
 Weight gain usually slow during the first 20
weeks

 Obesity can lead to gestational
diabetes & pregnancy induced
hypertension.

 Guideline for maternal weight:

- 2.0 kg in first 20 weeks
- 0.5 kg per weeks until term
- 12.0 kg approximate total weight
gain during the whole pregnancy
 Blood pressure
 Check the blood pressure every visit-
to know the baseline
 Whether within normal limit (of
pregnancy)
- 2nd trimester usually fall below pre-
pregnancy levels
- 3rd trimester usually goes back up
to the pre-pregnancy level
 Raise in systolic > 130 mmHg or /
diastolic > 90 mmHg – may indicate
pre-eclampsia or pregnancy induced
hypertension (PIH)
 Urine test
 Is performed to exclude abnormality
like presence of sugar & albumin
- urine albumin: dipstick test,
done every visit.
- presence of albumin 1+
(30mg/dl or more) – may
associated with pre- eclampsia,
urinary tract infection or
pyelonephritis
- urine sugar: dipstick test done every
visit.
- normally negative or trace
- if persistently presence of sugar
- green on two visit – refer to doc
for further investigation
- yellow/orange/red – refer
immediately. MOGTT (modified glucose
tolerance test will be done to detect
GDM)
 Blood Testing
 At first visit, blood test is done to
determine ABO blood grouping & Rhesus
(RH) factor, Heamoglobin, VDRL (Veneral
Disease Research Laboratory) test for
syphilis, Human immunodeficiency virus
(HIV)
- Rhesus factor
only mother with RH factor –ve will be
screened again at 28th, 32th, & 40th week
for the RH factor to ensure that the
pregnancy is not stimulating antibody
activity
- Heamoglobin level
-Hb is repeated at 28th weeks & 36th
weeks gestation to ensure that the
pregnancy is not stimulating
antibody activity.
-iron supplements may be given with
folic acid & vitamin to mothers
-iron is needed for forming hb
-folic acid is needed for forming red
blood cells
-vitamin C is vital for the optimum
uptake of iron.
• EXAMINATION OF PREGNANCY
 Examination head to toes (demonstration
will done in the nursing lab)
 General appearance, Observe:
hair: is it clean & well groomed?
face: - colour
- anaemic
- ? Anxious, unhappy, depressed,
lethargic
- eye, nose & ear- clean, any
discharges
- mouth – dental caries, any ulcer
Neck
- observe for swelling at thryoid
area
Hands
- is skin clean & free from septic
spots, ulcers
- any complaint of numbness of
fingers
Breasts examination done at every
visit
- observe the cleanliness of the
breast & advise mother on
cleaning the breasts
Nipple :
- Check that the nipple is protruding
enough so than baby can grasp it &
feed on during breast feeding
- Palpate the breasts gently with the

flat of hand to feel for any lumps.

- Advise mother to wear supportive

bras for comfort.

 Inspection of vagina
- Enquires on vaginal discaj

- ↑ during pregnancy

- Characteristics of the discharge

- amount
- colour
- odour
- any irritation
- If excessive, foul smelly & cause
itchiness-refer for treatment, advise
on personel hygiene
Check for edema
- Swelling of feet, ankles & hands is

common during pregnancy

- it can be uncomfortable for the patient,

but she can be reassured that it will go

away after delivery
- An effective treatment for edema:

- Bedrest

- Drinking plenty of water & avoiding

excessive salt
Abdominal Examination
Aims/The specific objectives are to
 Observe signs of pregnancy

 Assess fetal size & growth

 Assess fetal health

 Diagnose the location of fetal part

 Detect any deviation from normal

Abdominal Examination – steps
Abdominal inspection
- scars – LSCS
- size
- shape
- skin change
ABDOMINA
L
PALPATION
Abdominal Palpation (Leopold Maneuvers)
-steps
Palpate abdomen with hands that are clean &
warm. Cold hands tend to induce contraction
of the abdominal & uterine muscles & the
mother resents the discomfort of them.
c) Measure fundal height & estimating the period
of gestation (POG)
► place one hand just below the xiphisternum
► press gently & move the hand down the
abdomen until she feels the curved
upper border of fundus
► measure the distance of fundus from the
pubic bone up over the top of the uterus.
Use a tape measure.
measure the distance of fundus from the pubic bone up over the top of the uterus.
Use a tape measure.
► that distance, measured in centimeters
(cm),
► is approximately equal to the weeks of
gestation (1 cm = 1 week) – this
is known as MacDonald’s Rule.
► the height of the fundus correlates well
with gestation age.
► measurement falling within 1-3 cm of
expected value considered normal.
► fundal height 4cm different than
expected are considered abnormal &
suggest the need for further
investigation
► if a tape measure is unavailable, these
rough guidelines can be used :
● at 12/52, the uterus is just barely
palpate above the pubic bone, using
only an abdominal hand.
● at 16/52, the top of uterus is ½ way
between the pubic bone &
umbilicus.
● at 20-22/52, the top of the uterus is
right at the umbilicus.
● at full term,the top of the uterus is
at level of the ribs (xyphoid
process).
a) Abdominal Palpation
►Place the pregnant women in the
supine position & stand beside her
►Perform the first maneuver to
determine presentation/done to
determine whether it contains breech
or head at the fundus.
● facing the women’s head, place
both hands on the abdomen to
determine fetal position in the
uterine fundus.
● feels for the buttocks, which will
feel soft & irregular (indicates
vertex presentation); feel
First maneuver
Second
maneuver
► Second maneuver to determine
position

● while still facing the women, move

hands down the lateral sides of the
abdomen to palpate on which side the
back is (feels hard & smooth)
● continue to palpate to determine on
which side the limbs are located.
► Third maneuver to confirm
presentation
● move hands down the sides of the
abdomen to grasp the lower uterine
segment & palpate the area just above
the symphysis pubis.
● place thumb & fingers of one hand
apart & grasp the presenting part by
bringing fingers together
● feels for the presenting part. If the
presenting part is head, it will be around,
firm & ballottable. If it is buttocks, it will
feel sort & irregular
Third maneuver
►Fourth maneuver to
determine attitude of the
fetal head.
● the hand is moved
downward toward the
symphysis pubis.
● if you palpate a hard area
on the side opposite the
fetal back, the fetus is in
flexion coz you have
palpated the chin
● if the hard area is on the Fourth maneuver
same side as the back, the
fetus is in extension coz the
area palpated is the occiput
 AUSCULTATION
 Is done to assess the
fetal wellbeing
 Listen for the
heartbeat Fetoscope
 Check fetal heart for
rate, rhythm & tone
 FHR assessment can
be done by using
fetoscope or droppler
(ultrasound) or
continuously with an Using fetoscope
electronic fetal
monitor applied
externally or internally
Using daptone Using continuous external EFM device

Using continuous internal EFM

 Measuring FHR
 Purpose: To Assess Fetal Well-Being
 Assist the woman & have her lie down.
 Cover her with a sheet to ensure privacy
& then expose her abdomen.
 Palpate the abdomen to determine the
fetal lie, position & presentation.
 Locate the back of the fetus (the ideal
position to hear the heart rate)
 Place the fetoscope over the fetal back
 Listen for the sound of heart rate. Assess
the woman’s pulse rate & compare
 Once the fetal heart rate has been
identified, count the number of beats in
one minute & record the result
 Record the heart rate on the woman’s
medical record.
 FETAL ACTIVITY
● Fetal movement
● Not usually felt by the mother until the 16
weeks (for multigravida) & 20 weeks (for
primigravida)
● By ultrasound as early as 7-8 weeks
● movements increase in strength &
frequency through pregnancy
esp. at night (at rest)
● at 36/52 – normally a slow change in
movement with fewer violent kicks &
more rolling & stretching fetal
movement
● sudden decrease in fetal movement is a
● Kick Count/Fetal Kick
● ask the mother to count each distinct
fetal movement, starting from the time
she awakens in the morning.
● when reaches 10 movements or kick,
she is done counting for the day &
record in the fetal kick chart/fetal
movement chart
● if at 12 noon, hasn’t reached a count
of 10 movement-must report for further
investigation.
 HEALTH EDUCATION
● Objective (for the mother)
- ↑ confidence
- to have a healthy, happy pregnancy &
speedy rehabilitation afterwards
- prepares for labor
- prepares for a role of motherhood
● DIET
- Well balanced diet - ↑ dietary protein,
vitamins & mineral salt, iron
● REST & SLEEP
● CLEANLINESS
- encourage general hygiene
- clothing – comfortable & loose
● BOWEL
- constipation is common
- high fibre diet & fruit
- mild laxative if require
● SMOKING & ALCOHOL
-Impair of fetal growth, increase risk of
pre-term delivery & adverse effect on
intellectual development
● DRUG
- Should advice to avoid any form of
medication unless authorized by the
doctor
● BREAST CARE & BREAST FEEDING
● PREPARATION FOR DELIVERY
● HOW TO BATH BABY
● MINOR DISORDERS OF PREGNANCY
● IMMUNIZATION
- Inj. ATT (Anti-tetanus toxoid)
- to prevent neonatal tetanus if baby
having cord sepsis
- 1st dose – is given when the mother
feels the first fetal movement, normally
at 24/52 of pregnancy
- 2nd dose – at 4-6/52 later after the first
dose
- if mother’s subsequent pregnancy is
within the 3-5 year – booster dose of ATT
 FOLLOW – UP VISIT

PERIOD OF FREQUENCY OF VISIT

AMENORRHEA/PREGNAN
CY28/52
From UPT +ve till Every 4 weeks/monthly

28/52 - 36/52 Every 2 weeks

36/52 till delivery Every week
If any abnormality associated More frequent (e.g every
week)
THANK YOU