Mudaliar

and
Menon’s
Clinical
Obstetric
s
13TH EDITION
Chapter 8
PRE-
CONCEPTI
ONAL AND
ANTENATA
L CARE
 Pre-conceptional care refers to measures and
interventions that are undertaken before the
woman becomes pregnant with the aim to
PRE- improve maternal and neonatal health.
CONCEPTION It aims to identify and correct the potential risk
AL CARE factors that may have adverse effect during
pregnancy.

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A detailed medical, obstetric and family history should be taken to identify potential risk factors.
Detailed general examination to include weight, BP, blood profile and assessment of the
cardiovascular system should be carried out.
Anemia and malnutrition should be identified and corrected.
Advise should be given on ideal body weight prior to conception as both under weight and
obesity can have adverse effect on the mother and fetus.
All women should be started on 0.4 mg of folic acid to prevent neural tube defect in the fetus.
Those who are at increased risk because of a previously affected child, who have epilepsy and on
anti-epileptic medications should be given 4 mg of folic acid daily.
Advise on cessation of smoking, alcohol consumption and substance abuse should be given.
Vaccination history against rubella, chicken pox, hepatitis B should be verified.
The rubella status of the female should be checked. If seronegative, the fetus may be vulnerable
to anomalies if exposed to rubella during the period of organogenesis. Therefore, rubella
vaccination should be offered, and the woman should be advised not to become pregnant within
one month of immunisation.

GENERAL MEASURES

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Similarly, vaccination against chickenpox and hepatitis B can also be given prior to initiating the
treatment for infertility.
Pre-existing medical conditions such as diabetes, obesity, hypothyroidism, seizure disorders and
HIV should be managed appropriately before attempting conception.
The woman should be advised to avoid conceiving until the medical problem is well-controlled
or in remission.
The current medications should be evaluated in detail to avoid using teratogenic drugs and to
switch to safer drugs.
Those with cardiac diseases, autoimmune disorders or chronic renal disease and those who have
had a renal transplant should seek an opinion from the obstetrician and the respective specialist
to determine whether pregnancy can be undertaken.

GENERAL MEASURES

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  Should be on good glycemic control. Should aim
Pre-existing to have HbA1C <7 before starting pregnancy
diabetes  Evaluate for retinopathy, nephropathy, cardiac
status, etc.

Epilepsy • Use monotherapy; avoid teratogenic drugs;

increase the dose of folic acid

EVALUATION OF
Heart disease  Look for absolute contraindication for pregnancy
MEDICAL
 Assess functional state of the heart
CONDITIONS
 Avoid warfarin in those on valve replacement

Hypertension  Avoid ACE inhibitors

 Evaluate the cardiac status, look for retinopathy
and nephropathy

Hematological  In areas where hemophilia and thalassemia are

disorders prevalent, women should be counselled on the
risk of inheritance and the need for prenatal
diagnostic tests during pregnancy

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Screening for diseases
In women with recurrent pregnancy loss, genetic studies and other
investigations may be required
Identifying genetic risk factors in the family
In those with previous history of early onset pre-eclamsia/eclampsia APLA
screening is required
Screening for sexually transmitted diseases, UTI and treatment prior to
pregnancy is important to prevent preterm labour and intrapartum infections

Prevention of unintended pregnancies

There should be discussion on the prevention of unintended pregnancies and
spacing of children

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 Aims of antenatal care
To confirm pregnancy, assess gestational age, to
identify pre-existing medical illness and high-risk
factors, to order investigations and provide
prophylactic mediations
To monitor the well-being of mother and baby
To manage the ‘minor ailments’ of pregnancy
ANTENATA To prevent, identify and manage conditions that
L CARE may adversely affect the mother and the baby
To determine the timing and mode of delivery
To provide advice, reassurance, education and
support to the woman and her family
To achieve safe delivery
To ensure the birth of the infant in optimum
conditions

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Frequency of antenatal visits
The WHO proposes a minimum of four antenatal visits during
the antenatal period, which should be focused.
The first visit is in the first trimester to have a thorough
assessment of the patient.
2nd visit between 20 and 22 weeks to order an anomaly scan
as well as other screening investigations and start prophylactic
medications.
3rd visit is between 30 and34 weeks to identify evolving high- ANTENATAL
risk factors and to assess the fetal growth.
4th visit is at 38 weeks of gestation to plan the mode of
CARE
delivery.
However, most women, especially those with high-risk
pregnancies, should have antenatal care more frequently.
Booking visit before 10 weeks
Second trimester visit at 20–22 weeks
4 weekly appointments from 20 weeks until 32 weeks
Fortnightly visits from 32 to 36 weeks and weekly visits
thereafter

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 The booking visit should be carried out ideally at or
less than 10 weeks of gestation. It is usually carried
out as soon as pregnancy is suspected.

The purpose of booking visit is to:

To confirm pregnancy

THE FIRST To assess gestational age

TRIMESTE To rule out abnormal pregnancies

R VISIT To diagnose multiple pregnancy

To review medical history
To identify high-risk pregnancies
To assess general condition
To order investigations
To provide prophylactic medication

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CONFIRMATION OF
PREGNANCY
Symptoms: History of amenorrhea and presence of pregnancy
symptoms such as nausea, vomiting, giddiness, breast
tenderness and increased urinary frequency

Biochemical method: Positive urinary or serum

pregnancy test indicates the presence of serum beta-
hCG which confirms pregnancy

USG examination: The earliest evidence of pregnancy is the

appearance of the gestational sac which is identified by
transvaginal USG (TVS) as early as 4 weeks and is clearly
made out between 4.5 and 5 weeks of gestation; the mean
sac diameter is 2–3 mm at 4 weeks of gestation

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 The gestational age can be calculated
from the mean sac diameter. Adding 30 to
the mean sac diameter gives the
gestational age in days.

Example:
Mean gestational sac diameter 10 mm + 30 = 40
days (6 weeks)

The gestational sac should be evaluated

for the presence of a yolk sac and the fetal
pole.

The yolk sac appears at 5 weeks when the

sac diameter is 10 mm. Normally, the yolk
sac size is 6 mm, and it disappears at 12–
14 weeks. In the presence of large yolk
sacs, one should look for abnormal
pregnancy.

By 5.5 weeks, the fetal pole appears as a

1–2 mm large structure. Cardiac activity
appears at 6 weeks of gestation when the
embryo is >5 mm in size.

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DATING OF PREGNANCY (ASSESSMENT OF
GESTATIONAL AGE) AND CALCULATING
EDD
History
Elicit the first day of last menstrual period (LMP).
Also ask about the regularity of the previous menstrual cycles and use of contraception prior
to missing the period.
In a woman who has had regular menstrual cycles once in 28–30 days in the past, the
expected date of delivery (EDD) is calculated using Naegele’s rule.
Naegele’s rule: Add 7 days to the first day of the LMP and either go back 3 months or go
forward 9 months.
In women who have always had 40-day cycles, after calculating the EDD, add another 10
days to the EDD. This gives the corrected EDD. However, confirm the EDD using USG dates
also.
In women who have had very irregular cycles, Naegele’s rule cannot be applied. Instead,
USG parameters should be used.
Only 4–5% of women will deliver on their due date.

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DATING OF PREGNANCY
(ASSESSMENT OF
GESTATIONAL AGE) AND
CALCULATING EDD
USG to assess the gestational age
Crown–rump Length (CRL) measurement gives the
accurate estimate of the gestational age in the first
trimester, with which the EDD can be calculated
accurately to within 3–5 days.
The measurement is taken along the length of the fetus
in a straight line from the top of the head to the bottom
of the buttocks.
Usually, the measurement is taken at 7–14 weeks of
gestation.
If, for some reason, the EDD is not calculated in the first
trimester, then In the second trimester of pregnancy, the
biparietal diameter (BPD) is measured to assess the
gestational age.
The BPD is the widest transverse diameter of the fetal
head, taken between 14 and 20 weeks of gestation. With
the BPD measurement, the EDD can be accurately
calculated to +/- 7 days.

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The margin of error in calculating the EDD increases with gestational
age. Therefore, assigning gestational age should be done before 20
weeks of gestation.

If the woman reports for the first time late in the second trimester or
in the third trimester, femur length and trans-cerebellar diameters can
also be taken to assess the gestational age.

Accurate estimation of gestational age in first trimester is important

•To accurately calculate the EDD
•To monitor the fetal growth
•To avoid iatrogenic prematurity
•To plan induction for post-term pregnancy
•To interpret screening investigations such as Down screen

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 1. Demographic details
Age
Pregnant women at the extremes of age are
vulnerable to more complications than those in
their twenties and early thirties.
Pregnancy in teens is associated with higher
incidence of anemia, pre-eclampsia,
cephalopelvic disproportion (CPD) and more
BOOKING operative deliveries.
HISTORY Intrauterine growth restriction (IUGR) and pre-
term birth and miscarriages are also more
common.
Pregnant women over 35 years of age suffer
from diabetes, hypertension, malpresentations,
macrosomic babies, genetic abnormalities in the
fetus, especially Down syndrome.
Due to a macrosomic baby, such a woman can
develop CPD and obstructed labour.

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Occupation
It is important enquire whether the pregnant woman is working and about the nature of her
work.
Women who work or commute for long hours are vulnerable for pre-term births and IUGR.
The woman’s work may adversely affect her nutrition may not be met and may result in anemia.
Women working in laboratories and radiology departments are vulnerable to infection and
radiation exposure.

Residence
Women should be advised to reside closer to the hospital, especially in cases of hypertension,
placenta previa, multiple pregnancy, malpresentations and nearing term.
Socio-economic status
Assessing the socio-economic status helps gauge the nutritional status of the individual.
Women from low socio-economic groups suffer from anemia, under weight, preterm labour and
are likely deliver growth restricted and low birth weight babies. Women from higher socio-
economic strata may suffer from obesity and diabetes.

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2. Marital history
The number of years since marriage and history of consanguinity should be elicited.
In women who had infertility treatment, ascertain whether the pregnancy was spontaneous or
induced.
Consanguineous marriages may be associated with congenital anomalies of the fetus, autosomal
recessive disorders and single gene defects.
3. Menstrual history
A detailed menstrual history is important with regards to the regularity of cycles, duration of flow
and the first day of the last menstrual period.
For women with irregular cycles, those who do not remember their LMP and those who
conceived during lactational amenorrhea, the gestational age should be calculated by USG
parameters.
Besides the date, the amount of bleeding in the last menstrual cycle is also important. Scanty
bleeding that may be associated with ectopic pregnancy/implantation bleeding may be wrongly
taken as LMP.
4. Past medial history
History of past and current illnesses, past and current medications (for hypertension, diabetes,
renal disease, epilepsy, bronchial asthma, cardiac disease, thyroid disorders and autoimmune
diseases) should be elicited.
The medication may have to be changed or dose adjusted in pregnancy.

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5. Past surgical history
Appendicectomy, ovarian cystectomy (for adhesions), any surgical treatment to the cervix such as cone
biopsy, LLETZ for CIN lesions which can predispose for preterm labour

6. Past obstetric history

Calculate the obstetric score at the time of booking visit.
Obstetric score includes gravida, para, abortions, ectopic pregnancy, living children, etc.
Gravidity is the number of times the woman has conceived including the current pregnancy (all pregnancy
events should be included—abortions, ectopic, medical termination of pregnancy (MTP), pre-term births,
intrauterine death, etc).
a. Primigravida: A woman who is pregnant for the first time.
b. Multigravida: A woman who has conceived more than once.
c. Elderly primi: A woman who is pregnant for the first time at the age of 35 or more (in western
countries such terminology is not anymore).
d. Nulligravida: A woman who has never been pregnant
Parity is the number of times the woman has had a viable birth (as it involves delivery, the current
pregnancy should not be included).
The period of viability in India varies from 24–28 weeks of gestation depending on the available neonatal
facility. Period of viability is defined as the gestational age at which the > 50% of the newborns are able to
survive outside the uterus.

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In women who have delivered twins, the labour process is one, therefore, para 1 and
live 2.
For each conception, period of gestation and outcome of each pregnancy such as
spontaneous abortions, termination of pregnancy, ectopic, hydatidiform mole, pre-term
delivery/term delivery should be elicited.
Any antenatal complications anemia, pre-eclampsia, GDM, other medical complications
and the treatment given should be noted.
Details of the following should be collected:
Labour onset – spontaneous onset or induced (if induced indication for induction)
Gestational age at delivery – preterm, term, post-term
Mode of delivery – spontaneous vaginal delivery, instrumental delivery such as forceps
and ventouse, cesarean section (elective or induced)
Indication for cesarean section
Place and year of delivery
Whether the mother had any intrapartum complications
The birth weight of the baby, baby’s condition at birth, neonatal complications,
neonatal admission.
Postpartum complications such as PPH, maternal morbidity and whether blood
transfusion was given should be noted

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RECORDING PREVIOUS
OBSTETRIC PERFORMANCE

S.No. Year Period of Outcome of Antenatal Labour Mode of Sex/birth Postnatal

gestation pregnancy complications onset delivery weight/neonatal complications
complications
1 2005 14 weeks Spontaneous
abortion

2 2009 38 weeks Term delivery GDM Induced LSCS – M/3.9 Kg/hypoglycemia Nil
indication

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7. Previous gynecological history
History of previous heavy periods can predispose to anemia in pregnancy.
 Previous surgery on cervix can predispose for cervical incompetence.

8. Contraception history
History of contraceptive methods used prior to the current pregnancy should be elicited.
After using OC pills or injectable contraceptives such as DMPA, the EDD may not be accurate
as some of the cycles after stopping the contraceptive may be anovulatory.
Occasionally, a woman may become pregnant due to contraceptive failure.

9. Family History
Consanguinity
Hypertension, diabetes, pre-eclampsia, eclampsia
Multiple pregnancy
Congenital malformations, mental retardation, recurrent abortions, unexplained neonatal
death
Hereditary disorders
Blood transfusion in family members may indicate hereditary hematological disorders
History of having pets such as cats at home may predispose to toxoplasmosis infection

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10. Social history
Family support – nuclear or joint family, socio-economic status
Diet history
Smoking, drug abuse, alcoholism

11. Medication history

Current and past medication and allergy to drugs

12. History of current pregnancy

Whether planned or unplanned pregnancy
In the current pregnancy, the LMP, previous investigations and medications including
folic acid intake
Any complaints in the current pregnancy, any minor ailments such as nausea,
heartburn, vomiting, constipation, shortness of breath, dizziness, swelling, back-ache,
frequency of micturition, abdominal discomfort and headaches

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 Warning signs such as bleeding and pain
should also be enquired into.
It is also important to enquire about history
of exposure to possible viral infections, fever,
intake of medications in the first trimester as
WARNING well as inadvertent exposure to radiation
SIGNS such as X-rays and CT scan which can
predispose to congenital anomalies of the
fetus.
There may be excessive vomiting which
should not be ignored.

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 Height, weight and BMI
Short stature may be associated with small
gynecoid pelvis which can predispose for CPD
Low BMI is associated with fetal growth
BOOKING restriction, pre-term labour and low birth weight
babies
EXAMINATI High BMI is associated with pre-eclampsia, GDM,
operative interventions and anesthesia
ON complications
Look for evidence of anemia
Jaundice may be present in active viral infections
or in hemolytic anemia complicating pregnancy
Cardiovascular and respiratory system
examination

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 BP measurement is taken in the
recumbent /sitting position and Korotkoff
sound 5 is taken to define diastolic BP
Thyroid enlargement should be looked for
Breast examination for retracted nipple or
BOOKING any lumps

EXAMINATI Abdominal and obstetrical examination

Pelvic examination if required
ON Observe the gait of the individual as
shortening of the limb can occur following
polio, injury, tuberculosis of hip joint or it may
be congenial
Also examine the spine for kyphosis and
scoliosis; spinal deformities and shortening of
the limbs can affect the pelvic diameters

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Abdominal examination
Both abdominal and vaginal examination should
be performed only after asking the woman to
empty the bladder.
Until 12 weeks of gestation, the uterus is a pelvic
organ, and therefore not palpable per abdomen.
If the uterus feels larger than the period of
amenorrhea, the possibility of multiple gestation,
molar pregnancy, concurrent adnexal masses and
wrong dates should be suspected and confirmed by
USG.
Also look for undiagnosed abdominal pathology ,
liver and splenic enlargement.
Look for scars from previous surgery/ presence of
hernia.

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 First trimester vaginal examination is
mandatory when a woman presents with
amenorrhea, pain and bleeding for the
diagnosis of ectopic pregnancy and various
types of miscarriages.
With the availability of USG, bimanual pelvic
PELVIC examination is not usually carried out for the
assessment of the gestational age.
EXAMINATION
However, vaginal examination and examination
of external genitalia are important for the
diagnosis of vulval ulcers, warts, labial
adhesions, discharge and undiagnosed vaginal
septum , prolapse and other vaginal and vulvar
pathology.
In women who have never had a Pap test in
the past, it can be carried out.

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BOOKING INVESTIGATION
1. Complete hemogram: Gives hemoglobin levels
and hematocrit value which will indicate the
presence and severity of anemia (Hb levels should
be more than 11 gm%)
2. Blood group & RhD status:
If the woman is Rh-negative, her husband’s Rh
type should be checked.
If the husband is Rh-positive, pregnancy should
be monitored for the development of Rh
isoimmunisation and to take prophylactic
measures.
Indirect Coomb’s test is carried out in the first
trimester for those who have had previous
pregnancy events or blood transfusions to identify
whether Rh-isoimmunisation has already
occurred.

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3. Urine examination
Urine tested for glucose and protein during
every visit.
If the urine is nitrite-positive/has pus cells
>6/hpf, the mid-stream specimen is sent for
culture and sensitivity to diagnose asymptomatic
bacteriuria which may predispose to pregnancy
loss, preterm labour, pyelonephritis and pre-
eclampsia.
4. Screening for infections
Hepatitis B and C screening should be carried
out in all pregnant women to prevent perinatal
transmission to the newborn.
In order to prevent congenital syphilis, all
women are screened for syphilis using the
Venereal Disease Research Laboratory Test (VDRL)
or using the rapid plasma reagin (RPR) test.

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 HUMAN
IMMUNODEFICIENCY
VIRUS
All women should be offered HIV testing using enzyme-
linked immunosorbent assay (ELISA) and Western blot
test.
Universal screening is recommended for all pregnant
women to prevent transmission to the newborn and to
the uninfected partner. If a woman is HIV positive, early
treatment can be initiated.

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Testing for rubella IgG antibodies: Ideally discussed and performed in
the prenatal period . If the woman is not immune to rubella (i.e., if IgG
antibodies are absent), the woman is advised vaccination against rubella
before attempting pregnancy). If identified for the first time in pregnancy,
vaccination is carried out in the postnatal period to protect future
pregnancies.
TORCH (toxoplasmosis, rubella, cytomegalovirus and Herpes simplex)
screen: It is not routinely carried out in all pregnancies. Screening for
toxoplasmosis may be required if the individual has pets at home. The
test may be indicated while investigating pregnancy losses, congenital
anomalies and calcifications in the brain.

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5. Screening for diabetes
All pregnant women should be screened for gestational diabetes mellitus
(GDM).
In the oral glucose challenge test (OGCT), a 75 g glucose load is given,
irrespective of the last meal and a single blood sample is collected after two
hours.
In women who are unable to tolerate a glucose load because of vomiting,
fasting and postprandial blood sugar tests or a random blood sugar test is
performed along with an assessment of HbA1C levels.

6. Screening for thyroid disorders

If there are signs and symptoms indicating a thyroid disorder, a thyroid
function test is carried out.
In known cases of known hypothyroidism, TSH levels are checked to see
whether the condition is under control.

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7. Screening for aneuploidy
Trisomy 21 (Down syndrome), trisomy 18 and trisomy 13.
All pregnant women should be universally screened by NT thickness. Selective
first-trimester screening (FTS) is advised in high-risk women—age more than 35
years, a previous affected child, positive family history and diabetes complicating
pregnancy.
First trimester USG screening should be done for increased nuchal thickness—
abnormal accumulation of fluid behind fetal neck is measured as nucha thickness
(NT). The USG should be done between 11 and 14 weeks of pregnancy (first day
of 11th week to last day of the 13th week).
First trimester screening (FTS) with USG and biochemical screening—here,
besides ultrasound for NT thickness and measurement of human chorionic
gonadotrophin and PAPP-A levels are taken.
In women with fetuses affected by Down syndrome, the PAPP-A level is low
and serum beta hCG is raised.

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8. USG assessment in the first trimester
USG in the first trimester of pregnancy will give the following information:
Confirmation of intrauterine pregnancy
Diagnosis of abnormal pregnancy such as ectopic pregnancy and molar
pregnancy
Presence of heterotropic pregnancy (presence of both intrauterine and
extrauterine pregnancy)
In intrauterine pregnancies, USG gives information on:
Single or multiple pregnancy
Viability of the fetus

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GESTATIONAL AGE OF THE
FETUS
In multiple pregnancy, the GA gives information
about chorionicity, i.e., whether
dizygotic/monozygotic
Pregnancy complications such as miscarriages
Markers for Down syndrome by NT thickness
Congenital anomalies such as anencephaly can be
picked up in the first trimester of pregnancy (anomaly
scan is carried out at 18–20 weeks of gestation)
Congenital anomalies of the uterus
Associated benign tumours of uterus such as fibroids
Adnexal pathology such as ovarian tumours (corpus
luteal cyst is the physiological cyst of pregnancy and
disappears after 12 weeks of gestation)

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At the end of first Age <18 years or >35 years
trimester, one should be
Gravida Primigravida and grand multipara
able to identify
pregnancies that are at Previous obstetric Previous cesarean section, previous preterm labour, PROM,
high risk. history termination of pregnancy on >2 occasions, previous stillbirth,
neonatal death, IUGR, macrosomia, pre-eclampsia or
Even women who are
eclampsia, GDM, fetal abnormality, PPH, genetic disease in
at low risk may the family
subsequently develop
complications that place Current Pre-eclampsia, GDM, anemia, other medical illness, smoking,
them in the high-risk pregnancy Rh-incompatibility, bleeding in early and late pregnancy,
category. poor weight gain, pregnancy following ART techniques

Women with the Examination Short stature, BP > 140/90, pre-pregnancy weight >85 Kg,
following findings come <45 Kg, uterus large for dates/small for dates, multiple
under high-risk group: pregnancy, malpresentations, polyhydramnios

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 1. History:
General questions regarding maternal well-being
Any specific complaints such as pain, bleeding
Headache, diminished urine output, reduced/loss
SUBSEQUE of fetal movements, sudden increase in weight,
generalised edema/breathlessness, vomiting
NT Enquiry regarding fetal movements—the fetal
ANTENATA movements are usually felt by 18 weeks in a
L VISITS primigravida and 16 weeks in a multigravida; the
perception of the first fetal movement by the
mother is called quickening and it depends on the
observation of the individual
Any other specific complaints or concerns

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2. Examination:
Look for anemia and pedal edema
Measure blood pressure
Check maternal weight: Average weight gain from
2nd trimester onwards is 0.5 Kg per week

Abdominal palpation for fundal height

There are three landmarks in the abdomen; namely
symphysis pubis, umbilicus and the xiphisternum.
Between the symphysis pubis and the umbilicus
draw two equidistant lines
At 12 weeks of gestation, the uterus is just palpable
per abdomen above the symphysis pubis, especially
in thin individuals.
The first line corresponds to 16 weeks and the
second line corresponds to 20 weeks of gestation.
If the fundus is felt at the level of the umbilicus, it
corresponds to 24 weeks of gestation

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Draw another two lines between the umbilicus and
xiphisternum at equal distance. The third line will
correspond to 28 weeks of gestation and the fouth
line corresponds to 32 weeks of gestation.
Fundal height at the xiphisternum corresponds to
36 weeks of gestation.
The uterus cannot grow upwards beyond the
xiphisternum because of the presence of the
diaphragm. Therefore, the uterus enlarges in the
transverse direction and there is descent of the
presenting part (cephalic/breech) into the pelvis. As
a result, the fundal height decreases and at 38
weeks, corresponds to 34 weeks and at 40 weeks
corresponds to 32 weeks of gestation.

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 DIFFERENTIATING BETWEEN
32 WEEKS AND 40 WEEKS OF
GESTATION
At 40 weeks, as the level of fundus comes down, the
pressure on the abdominal organs and the discomfort
due to the elevated diaphragm is reduced. As a result, the
patient feels relieved; this is called “lightening”.
Due to the transverse enlargement of the uterus, the
flanks will be full.
The woman is asked to sit at the edge of the bed with
her legs hanging. At 40 weeks of gestation, the uterus will
fall forward, especially in multigravid women.
Falling forward of the Because the uterus is falling forward, one may be able to
uterus and shelving
keep the hand behind the fundus which is called shelving.
At every visit, the fundal height should be checked by
palpation to determine whether it corresponds to the
dates.

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Also feel for the fetal parts (also called external ballottement). With the
hands on either side of the uterus, tap the abdomen with one hand; the fetus
will move and touch the other hand.
This can be elicited upto 24 weeks of gestation.
If the height of the uterus is more than the period of gestation, consider the
possibility of multiple pregnancy, hydramnios, wrong dates, large baby and
uterine /adnexal tumours.
If the height of the uterus is smaller than the period of gestation, consider
the possibility of wrong dates, oligohydramnios, IUGR .
CHECKING THE FETAL HEART
From 16 weeks onwards, the fetal heart can be heard using a handheld
Doppler. A fetoscope can be used after 24 weeks of gestation.

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CLINICAL ASSESSMENT OF GROWTH OF THE FETUS
With a flexible inch tape, the measurement is
taken from the symphysis pubis to the fundus
(symphysiofundal height (SFH).
Between 20-34 weeks of gestation, this
measurement in cms equals the gestational age in
weeks.
If the SFH is less than 4 cm for the period of
gestation, IUGR, isolated oligohydramnios and
wrong dates should be suspected, and
investigations carried out.
Serial measurements are taken and plotted on a
graph (gravidogram). This is a very simple and
inexpensive method to pick up IUGR in low-
resource settings. This measurement is not
applicable when there is oblique or transeverse
lie.
If the SFH is more than the expected
measurement, one should consider macrosomia,
multiple pregnancy and wrong dates.

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 INVESTIGATIONS AT
EACH VISIT
Full blood count
Urinalysis for protein, blood and glucose
and pus cells
Screening for GDM at 24–26 weeks and at
34 weeks
In Rh-negative mothers, indirect coombs
test
Indications for USG in second and third
trimesters of pregnancy

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 USG assessment in the second and third trimesters of pregnancy

18–22 weeks  Anomaly scan

 Doppler study in high-risk cases for pre-eclampsia
and IUGR

After 24 weeks •Fetal echo in type I diabetes, GDM, family

history/mother suffering from heart disease, mother
suffering from auto-immune diseases, esp. SLE

32–34 weeks • In cases of placenta previa, look for adherent

placenta (MRI may be indicated)

Serial scans from 28 • In IUGR, diabetes

weeks every 3–4 weeks

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ASSESSMENT AT 36 WEEKS OF
GESTATION
The general condition of the patient should be assessed.
The woman should be educated on the symptoms of labour pains.
Complications should be looked for
Abdominal examination
Look for longitudinal or transverse enlargement of the uterus
Check for overdistension of the uterus
Look for the scars and hernia
From 36 weeks onwards, the lie of the fetus (longitudinal, transverse or
oblique), its presentation (cephalic or breech) and the degree of
engagement of the presenting part should be assessed and recorded.

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 95% of fetuses at term
present by the vertex in
labour. Hence, this is
called normal
presentation.
The height of the uterus
should be assessed with
the ulnar border of the left
hand.

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 1. Fundal grip
The palm of the hands are placed
on either side of the fundus and
Abdominal palpation involves the abdomen is palpated to see
four manoeuvres (Leopold’s which part of the fetus is occupying
manoeuvre). Before palpating the fundus.
the abdomen, the clinician If the breech is occupying the
should explain what he/she is
fundus, it is broad, soft and not
going to do. In order to get independently ballotable from the
good relaxation, the woman is body.
made to lie on her back with
the thighs and knees flexed. When the breech is moved, it
The clinician stands on the moves the body of the fetus as
patient’s right side facing her well.
head. If the head is occupying the
fundus, it is rounded, hard and
independently ballotable.
In transverse lie, the uterus is
enlarged transversely, and the
head will be palpated in one of the
loins.
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2. Umbilical grip
The palms of the hands are closely applied to the uterus to
palpate from the fundus to the lower part of the uterus to
identify the side of the spine and the limbs.
On the side of the spine, there is uniform resistance, and the
abdomen feels curved. On the side of the limbs, the abdomen
feels nodular, irregular, and one can dip the fingers in between
the nodules.
The fetal spine is felt more easily and is anterior in
occipitoanterior position and is felt towards the flank in
occipitoposterior position.
The limbs will be more anterior and can be felt easily in certain
presentations such as direct occipitoposterior position, when the
dorsum is posterior in transverse lie and in multiple pregnancy.

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3. First pelvic grip (Pawlik’s grip)
This manoeuvre helps in identifying the presenting part,
i.e., the part of the fetus that is occupying the lower pole
of the uterus.
The right hand of the examiner is kept wide open and
applied to the lower abdomen above the symphysis pubis
(one should make sure that the bladder is empty).
The presenting part is grasped between the fingers and
palpated to see whether the head or the breech is
occupying the lower pole.
The head will feel hard and rounded, whereas the breech
will feel soft, broad and irregular.
 In transverse lie, the lower pole will be empty.
The presenting part is moved to see whether it is
possible to move from side to side. If it is possible to move
it easily, the presenting part is said to be mobile/floating.
if it does not move, then it indicates that the presenting
part has entered the pelvic brim where it may be just fixed
or engaged.

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 4. Second pelvic grip
Helps in re confirming the presenting part as well as
in identifying the attitude of the fetus and to see
whether the head is engaged or not.
In carrying out the second pelvic grip, the examiner
faces the patient’s feet and by keeping the hands on
either side and palpating, confirms the presenting
part.
In order to identify the attitude of the fetus, the
examiner palpates on the side of the spine.
The first bony prominence on the side of the spine
that will be felt will be occiput, and the bony
prominence that is felt on the opposite side will be
the sinciput.
Whether the head is flexed, extended or deflexed is
made out by identifying the relation between the
occiput and the sinciput.

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When the head is well flexed the occiput is at a lower level than the sinciput.
When the head is extended as in brow and face presentations, the occiput is
at a higher level than the sinciput and one can feel a groove between the fetal
spine and the occiput.
When the head is deflexed as in the occipitoposterior position, both occiput
and sinciput are at the same level.

ENGAGEMENT
Engagement means that the greatest transeverse diameter of the fetal head,
i.e., the biparietal diameter, has gone through the brim of the pelvis.
When the head is engaged, only the sinciput or no parts of fetal head will be
palpable per abdomen and the hand will be diverging.

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 Cephalic prominence
It is that part of the fetal head that is felt first
and prominent on palpation.
In a well-flexed head, the cephalic prominence is
the sinciput.
In an extended head, the cephalic prominence is
the occiput.

Abdominal palpation also yields the following:

information:
By abdominal examination, CPD can also be
assessed
Clinically one can assess the amount of liquor
The gestational age and estimated weight of the
fetus can be estimated by clinical examination
using SFH
 Serial measurements are necessary.

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The fetal weight assessment by Johnson’s rule:
Approximate fetal weight in g = fundal height in cm – n X K (constant 155)
N= 12 if fetal head is below the spines
11 if fetal head is above the spines

Assessment of gestational age by MacDonald’s rule:

Duration of gestation in weeks = fundal height X 8/7

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Auscultation
The fetal heart is located using either either a fetoscope or a handheld
Doppler.
Fetal heart is heard on the side of the back.
In cephalic presentations, it heard below the levelof the umbilicus and in
breech presentation above the level of the umbilicus.
Vaginal examination
After explaining the procedure and obtaining consent from the woman,
vaginal examination should be performed using sterile gloves. After
cleaning the vulval area with antiseptic solution, two fingers are inserted
gently into the vagina and examination carried out.
The bladder should be emptied prior to examination.

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In all primigravid women and multigravidae in whom there was a previous obstetric
mishap, vaginal examination is carried out after 38 weeks of gestation to check the
adequacy of the pelvis.

Prior to induction of labour, vaginal examination is performed to assess the

favourability of the cervix.

Vaginal examination is contraindicated in suspected or confirmed placenta previa or in

the presence of PROM toavoid introducing infection.

Assessment of pelvis

It is important to assess the capacity and adequacy of the pelvic prior to delivery.

Though a definite diagnosis of CPD is made after delivery, in certain situations, a

diagnosis of CPD can be made even prior to delivery such as in the case of a small
gynaecoid pelvis in short-statured women, for an obliquely contracted pelvis as in polio,
kyphoscoliosis or due to injury or infection affecting the joints.

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 Whether the sacral promontory is reached or not
Curvature of the sacrum from above downwards
and laterally
Pelvic side walls—whether parallel or converging
While Whether the sacrosciatic notch admits two fingers
assessing the Whether the ischial spines are prominent or not
pelvis the Whether both spines are reached wit stretched
following index and middle fingers
should be Whether the subpubic angle is acute or obtuse
noted: and whether it admits the back of two fingers
Intertuberous diameter – the distance between
the two ischial tuberosities should admit
approximately four knuckles
It is not sufficient to assess the pelvis; it is
important to also assess for CPD

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 ASSESSMENT AT 40 WEEKS OF
GESTATION
Mode of Assess the well-being of the mother
delivery and the fetus.
If the fetal well-being is satisfactory
and there are no maternal
It is often at this
appointment that a
contraindications, await spontaneous
decision is made regarding delivery for 7 days with a kick chart and
the mode of delivery (i.e., careful fetal surveillance.
vaginal delivery or
planned ceserean section). Membrane sweeping can be done at
40 weeks.
AT 41 WEEKS OF GESTATION
If undelivered at 41 weeks, plan
induction of labour/cesarean section

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 The expectant mother is instructed about
diet, relaxation and sleep, bowel habits,
DVICE exercise, bathing, clothing, avoidance of hard
TO THE and tiring work, recreation and follow-up
visits.
EXPECTA The need for regular attendance at the clinic
NT should be emphasized.
MOTHER Restriction of sexual intercourse and its
avoidance in the first and last few weeks of
pregnancy are beneficial.
The warning signs in pregnancy should be
explained and the woman should be
instructed to report immediately.

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 Bleeding per vaginum Leakage of fluid

Abdominal or pelvic pain Fever

Warning Swelling of the face or Persistent vomiting
signs limbs Breathlessness
Generalised edema Dizziness
Blurring or dimness of Dysuria
vision
Diminished fetal
Persistent headache, movements/excessive
frontal headache, fetal movements
vomiting
Reduced urine output

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NUTRITI In a country like India where malnutrition is rampant,
affecting both maternal and fetal well-being, it is essential
ON AND that the pregnant woman be suitably advised regarding

DIET her diet.

DURING Nutritional advice should take into account foods

available locally and beliefs regarding them, cooking
PREGNA facilities, patterns of meals, and whether the pregnant
woman is working and the type of work she is doing.
NCY In general, the pregnant woman should be advised to eat
whatever she likes in the amounts she desires and salted
to taste, as long as the diet contains calories, proteins and
various nutrients in recommended amounts.
With regard to dietary supplements, according to the
GOI, 100 mg of elemental iron and 500 mcg of folic acid
should be taken daily for 100 days during pregnancy.

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Calcium supplementation is also advised in a dose of 1,000 mg/day. IFA (iron-folic acid)
tablets are also given during the lactation period. Besides iron supplementation,
deworming with one tablet of albendazole is also given to prevent anemia.

Nutrient Non-pregnant Pregnant women Lactating

women women

Energy (Kcal) 2200 2500 2600

Protein in g 45-50 (1gm/Kg) 60-75 (1.5gms/Kg) 70-75
Calcium in g 0.8 1.2 1.2
Iron in mg 15 60 30
Folate mcg 180 400 280
Vitamin D mcg 5 10 12

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WEIGHT GAIN IN PREGNANCY
Depending on the pre pregnancy weight, different levels of
weight gain are recommended for pregnant women.

BMI Recommended weight gain in

pregnancy

Low BMI <20 12.5 – 18 Kg

Normal BMI 20-25 11.5-16 Kg

High BMI 26-30 7-11.5 Kg

Obese >30 Not more than 6 Kg

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 Vaccination in pregnancy protects not only the mother
but her baby for 6 months postpartum. FOGSI
recommends immunisation against tetanus, diphtheria,
pertussis and influenza during pregnancy.
It is important that all pregnant women be immunised
against tetanus, as neonatal tetanus is a common cause
of perinatal mortality.
When the patient is seen in the first trimester, tetanus
toxoid can be given in two doses separated by eight
IMMUNISA weeks—the first at 16–20 weeks and the second at 20–24
weeks.
TION
For those who have already been immunised, one
booster dose of tetanus toxoid should be given in a
subsequent pregnancy, preferably four weeks before the
expected date of delivery.
If the subsequent pregnancy occurs within 5 years, only
one booster is given.
Tetanus diphtheria acellular pertussis (T-dap) vaccination
can be considered instead of the second dose of tetanus
toxoid to offer protection against diphtheria and pertussis
in addition to tetanus.

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The objectives are cleanliness and
encouragement of circulation to keep the lacteal
sinuses and ducts open to allow colostrum and
milk to escape freely under the pressure of
secretion.
The woman should wash the breasts twice daily.
Tight brassieres should be avoided.
CARE OF THE
Washing with lukewarm water after each act of
BREASTS
breastfeeding is recommended.
Retracted nipples should be identified during
pregnancy and corrected by the syringe method
after 36 weeks of gestation (earlier attempts may
induce preterm labour due to nipple stimulation).

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 COMMON CONCERNS DURING
PREGNANCY
Exercise
Pregnant women may exercise provided they do not get excessively fatigued.
Women who are accustomed to aerobic exercises before pregnancy may
continue this during pregnancy but should not intensify the exercise.
In women who were previously sedentary, activity more strenuous than
walking is not recommended.
Women with hypertensive disorders, multiple pregnancy, growth-restricted
fetus and heart disease should avoid high-impact exercise; minimal walking can
be allowed.
Work
Women can continue with their employment until they go into labour if the
pregnancy is uncomplicated.

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Travel
Travel by car and train is safe for pregnant women.
Self driving of two-wheeler should be avoided.
Four-wheeler driving can be undertaken with care until the early third trimester of
pregnancy.
Long distance air travel should be avoided for fear of venous thrombosis.
Bowel habits
Constipation is common in pregnancy because of the prolonged transit time and
compression of the large bowel by the uterus.
Taking sufficient amount of liquids, high-fibre diet, regular exercise and mild laxatives when
necessary can prevent it.
Coitus
If there is a history of previous abortion, intercourse should be avoided in the second and
third months.
Intercourse does not affect the fetus but is best avoided from week 36 of pregnancy till six
weeks after delivery.

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Drugs
It is advisable to avoid using drugs, if possible, particularly in the early weeks when
embryogenesis is taking place. Most drugs cross the placenta to reach the embryo or
the fetus.
If a drug is required and administered during pregnancy, the benefit must clearly
outweigh any risks inherent in its use.

Heartburn
The cause is gastroesophageal reflux due to relaxation of the lower esophageal
sphincter.
Taking small frequent meals, avoiding lying supine or prone and using antacids
whenever necessary may help relieve symptoms.

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Increased vaginal discharge
Increased vaginal discharge is common during pregnancy and unless associated with
itching /irritation, it is usually non-pathological and may be dueto increased mucus
production by the cervical glands.
Carpal tunnel syndrome
Tingling and numbness (paresthesia) over the thumb and the lateral two and half
fingers are common complaints.
This is due to the compression of the median nerve and perineural edema.
Splinting the wrists and small doses of diuretics are advised in severe cases.
Backache
Low backache is very common in pregnancy.
It can be minimised by having women squat rather than bend over to reach down and
using back support while sitting and avoiding high-heeled shoes.

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Varicosities
These are exaggerated by pregnancy and prolonged standing.
Treatment is usually limited to periodic rest with elevation of the legs and use of
elastic stockings.
Hemorrhoids
These are exaggerated during pregnancy due to increased pressure in the rectal veins
caused by obstruction of venous return by the large uterus and the tendency to
develop constipation during pregnancy.
Treatment consists of topically applied anesthetics, warm soaks and stool softeners.

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