EDITED

ANTENATAL CARE CASE SHEET

I] Particulars of the patient
A) Patient details B) Records
 Name
 Date of examination
 Age
 Hospital number
 Education
 Diagnosis
 Occupation
 Results cured / operated
 Socioeconomic status
 Address including
contact number

II] Presenting symptoms / complaints

A) History of amenorrhoea – in lunar /calendar months
B) Complaints – Came for routine ANC check-up or
C) Actual complaints – History of
 Nausea  Convulsions
 Vomiting  Disorientation
 Bleeding PV  Unconsciousness
 Leaking PV  Backache
 Loss of foetal movements  Headache
 Excessive foetal movements  Breathlessness
 Burning micturition  Blurring of vision
 Pain in the abdomen  Swelling of feet
 Pain in the scar of previous LSCS  Puffiness of face
 Yellowish discoloration of eyes
and urine
III] Details of the present complaints
A) How did it start? D) Any treatment taken for it?
B) When did it start? E) What happened to the complaint?
C) Progression?
0
 IV] Obstetric History
A) 1. Married life

2. Consanguineous marriage

3. Obstetrics score - 1. Gravida

2. Para
3. Abortion
4. Stillbirth
5. Neonatal death
6. Living

B) Details of the previous pregnancy

Sr. Period of Delivery Normal / Caesarean Place of

No gestation status Assisted section operation

( If Indications) (If Indications) Home / Hospital

Sr. Who What was Status of baby Breast Contraception

No conducted outcome feeding used
Hospital

Mother Baby Alive / Dead

NOTE –

In abortion In Neonatal death

-Spontaneous or induced -Cause of death

-Eventful or uneventful -Admitted to NICU or not

-Duration of labour

-Post- abortal period

C) 1. Last delivery

2. Last abortion

3. Last childbirth

4. Contraception used if any

5. High risk pregnancy

V] Menstrual History
1. History of menarche Scanty

Moderate
2. Past cycles – days, regular/ irregular, amount of flow
Severe
Associated with dysmenorrhoea or not.

3. Cycles before amenorrhoea – (Ask same as above)

4. Last menstrual period

5. Expected date of delivery (By Naegele’s formula – LMP + 9 Months and 7 Days)
Excellent
6. Dates
Good

VI] Medical History – History of

1. Any treatment taken for infertility.

2. Diabetes, Hypertension, Tuberculosis

3. Blood transfusion

4. Drug allergy

5. Asthma
Tonsillectomy
6. Surgeries -
Appendicectomy

Dental caries

Previous D and C

VII] Family History – History of

1. Diabetes, Hypertension, Tuberculosis

2. Anomalous baby

3. Twin pregnancy
VIII] Personal History – History of
1. Diet

2. Appetite

3. Loss of weight

4. Bowel and bladder habits

5. Sleep pattern

6. Any addiction

IX] Provisional diagnosis

EXAMINATION
I] General Physical Examination
My __ (Patient Name) is looking around __years old, built, nourishment.

She is comfortable, cooperative and oriented to time, place and person.

She is anaemic or not Height - cm Blood pressure - mm/Hg

Cyanosis - present or not Weight - kg Oral hygiene -

Clubbing - present or not Temperature- Skin -

Icterus - present or not Pulse -

Pedal oedema - present or not

Examination of -
1. Breasts

2. Thyroid

3. Spine
II] Systemic Examination
A) Respiratory system - Bilateral air entry [ If abnormal then do
- Crepitations Inspection
- Rhonchi Palpation
- Vesicular breathing Percussion ]
B) Cardiovascular System
1. 1st and 2nd heart sounds are heard in all 4 areas – heard or not

1st heart sound - Low pitch long - Coincides with maternal pulse.

2nd heart sound – High pitch short - More heard in aortic and pulmonary area

2. Any added sounds – 3rd or 4th heart sound

3. Any murmurs – Systolic or Diastolic
C) Nervous System
Higher functions
1. Central nervous system
Cranial nerves

Motor system
2. Peripheral nervous system
Sensory system
D) Abdominal System

1. Inspection –

Expose the abdomen from xiphisternum to pubic symphysis.

Flex the legs at the level of thighs.

Abduct at hip joint.

Stand at the right side of the patient.

For inspection fully extend the knee joint. What you note:

i) Height of the uterus in terms of weeks of gestation.

ii) Vertically transverse or stretched.
iii) Umbilicus inverted or everted.
iv) Skin overstretched or shiny.
v) Any foetal movements.
 vi) Any scars in the abdomen – Linea nigra
Stria gravidarum
vii) Femoral area – ask lady to cough – check for femoral hernia.
viii) Any dilated veins.

2. Palpation

To be conducted in a well-lit room

Empty the patient’s bladder
Warm up your palms
Flex the knee to 90 degrees.
Abduction at the hip joint.
Face and talk to the patient.
a) Height of uterus-Right hand is used to correct dextrorotation.
- Left hand ulnar border from above downwards is
used to palpate height of uterus. (In weeks of
gestations)
Xiphisternum 36 weeks
Umbilicus 24 weeks
Pubic Symphysis 12 weeks

b) Uterus - tense or tender? acting or not?

c) Fundal grips -

i) Face fundal grip –What is there in the fundus?

broad, soft and irregular mass s/o breech or

smooth, hard and globular mass s/o head

ii) Lateral or umbilical grip- With one hand medialise the uterus

With other hand palpate for the structures

smooth curved resistant feel s/o back

empty knob like irregular parts s/o limbs

 iii) 1st pelvic grip / Feet fundal grip /Pawlik grip/ Superficial fundal grip-

Face the patient’s feet.

Take your right hand. (Only grip with one hand)

Put ulnar border over pubic symphysis and grip gently.

Palpate what is there, size, consistency , mobility.

iv) 2nd pelvic grip/ Deep fundal grip –

Use 2 hands.

Face the patient’s feet.

a. Confirm the presentation (Cephalic or breech)

b. Try to insinuate both the hands in between presenting

part and pelvis. (Engaged or not)

If easily insinuate – fully flexed.

c. Attitude –

Head not palpable Head engaged Look for occiput and synciput level

Fully flexion Occiput is at lower level Vertex presentation

than synciput and only
synciput is felt.
Deflexion Both occiput and Brow presentation
synciput are felt.
Fully extension Occiput is at higher Face presentation
level than synciput

d. Check maturity (Size of the head, big or small)

How many fingers palpable over the head? 5/5 fingers Unengaged

2/5 fingers Engaged

When head is only 2 fingers palpable, lowermost part of the head of the baby
is at the level of the ischial spine Do PV for the same
 -5
-4
-3
-2
-1
Ischial spine
+1
+2
+3
+4
+5
If head is ballotable and not engaged even after 36 weeks

2nd pelvic grip should be done to know the attitude

3. Percussion -

Done only if there is over-distension - 1. Fluid thrill

2. External ballottement – if more fluid thrill

4. Auscultation –

Presentation Location of heart sound

Vertex Below umbilicus
Breech Above umbilicus
Occipitoanterior Towards midline
Occipitoposterior Away from midline
Auscultate for –

i. Maximum intensity
ii. Rate
iii. Rhythm
iv. Tone
v. Location
vi. Relationship between uterine contraction and foetal heart sound.
5.Measurements –

i. Height of uterus (in cms)

Symphysio-Fundal height

Fix one end to the symphysis fundus with left hand

Move up to the fundus with right hand, keeping a book at the top of the
fundus

ii. Girth at the level of umbilicus (in inches)

After 28 weeks of gestation, Symphysio-Fundal height (cms) directly gives the

gestational age in weeks.

After 28 weeks of gestation, girth (inches) directly gives the gestational age in
weeks.

Johnson’s Formula

Symphysio-Fundal Height × 2/7 = Gestational age in months

Symphysio-Fundal Height × 8/7 = Gestational age in weeks

DIAGNOSIS
1. Patient’s Name
2. Age
3. How many weeks of gestation?
4. Single pregnancy/not
5. Gravity and Para
6. Lie
7. Presentation
8. Position
9. Station
10.Pelvic adequate or not
11. Is she is in labour or not? (active or latent)
12. Any complications/pathology in the form of anaemia/DM/HTN/Previous
LSCS
13. Reasons for coming to the hospital/OPD
POINTS TO REMEMBER
Bad Obstetric History (BOH) -

Present pregnancy where previous pregnancy was lost.

Criteria: 1. Two consecutive abortions in first trimester OR

2. One intrauterine death OR

3. One neonatal death

High Risk Pregnancy (HRP) –

Pregnancy where there is risk for both mother and baby.

Examples: 1. Patient with twin pregnancy

2. Breech presentation

3. Short stature patient

4. Oligohydramnios / Polyhydramnios

5. Elderly primi

Criteria for excellent dates -

1. Cycles are regular and normal.

2. Scan date matches with last menstrual period.
3. Patient is not on ORAL CONTRACEPTIVE PILLS.

Criteria for good dates -

1. Cycles are regular.

2. Last menstrual period if she remembers properly.

Dating scan – In case of pregnancy USG in 1st trimester within 10 weeks

assess the gestational age.

Importance - 1. Helps in identifying intra-uterine growth retardation.

2. Helps in knowing when to induce labour.