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.
