MATERNAL ASSESSMENT

HISTORY TAKING
INTRODUCTION:

In history taking one need to explore and inquire in to personal and often
intimate problems. Hence, developing a good rapport with the patient and winning her confidence
are of paramount important. The need for greeting the patient, proper introduction, creating a
friendly and relaxed atmosphere and privacy cannot be overemphasized.

It is the best to have an outline, which will enable us to elicit the relevant
information to reach a differential diagnosis at the end of our history taking.

Such an approach will guide us through the clinical examination and may also help
us to plan our investigation.

OBJECTIVES:

 To build the foundation for a trusting relationship in which the women and midwife are
partners in care
 To assess the health and screen the high risk cases
 To identify the risk factors by taking accurate details of past and present midwifery,
obstetric, medical, family and personal history
 To provide an opportunity for the women and her family to express and discuss any
concerns they might have about the current pregnancy and previous pregnancy loss, labour,
birth or puerperium.
 To give public health advice pertaining to pregnancy in order to maintain the health of the
mother and fetus
 Make appropriate referral where additional health care or support needs have been
identified.

HISTORY TAKING:

VITAL STATISTICS:

Name:

Age: a women having her first pregnancy at the age of 30 or above is called elderly Primi
gravida. Extremes of age teenage and elderly are obstetric risk factors.

Address:

Gravida and parity: Gravida denotes a pregnant state both past and present, irrespective of the
period of gestation. Parity denotes a state of previous pregnancy beyond the period of viability.

Gravida and para refer to pregnancies not to babies, as such a women who delivers twins in
first pregnancy is still a gravida one and para one.
 A pregnant woman with a previous history of two abortions and one term delivery can be
expressed as fourth gravida but primipara.

It is customary in clinical practice to summarize the past obstetric history by two digits (the
first one relates with viable births and second one relates with abortion) connected with a plus
sign affixing the letter P thus P2+1 denotes the patient had two viable births and one abortion.

A pregnant women with a previous history of four births or more is called GRAND
MULTIPARA.

DURATION OF MARRIAGE: this is relevant to note the fertility or fecundity. A pregnancy long after
marriage without taking recourse to any method of contraception is called low fecundity and soon
after marriage is called high fecundity. A women with low fecundity is unlikely to conceive
frequently.

Religion:

Occupation: It is helpful in interpreting symptoms fatigue due to excess physical work or stress or
occupational hazards. Such women should be informed to reduce such activities.

Occupation of husband: A fair idea about the socio economic condition of the patient can be
assessed. This knowledge is of value

 To anticipate the complications likely to be associated with low social status such as
anaemia, preeclampsia, prematurity etc
 To give reasonable and realistic antenatal advice during family planning guidance.

Period of gestation: the duration of pregnancy is to be expressed in terms of completed weeks. A

fraction of a week of more than 3 days is to be considered as completed week. In calculating the
weeks of gestation in early part of pregnancy, counting is to be done from the first day of “last
menstrual period”(LMP) and in later months of pregnancy, counting is to be done from “expected
date of delivery (EDD)” .

The EDD is calculated by “ Naegele’s rule, in which 7 days are added to the date of the first
day of LMP and 3 months are subtraction from that date .

It is also calculated by adding 9 calendar months and 7 days to the date of the first day of the
women’s last menstrual period.

The actual period of gestation is from the time of fertilization. Since ovulation is generally
considered to occur approximately 14 days before the next menstrual period, the length of a
women’s menstrual cycle will affect the accuracy of EDD.

The majority of women will deliver within 10-14 days either earlier or later of their EDD.

Complaints: categorically, the genesis of complaints is to be noted. Even if there is no complaints

enquiry is to be made about the sleep, appetite, bowel habits and urination.
 History of present illness: elaboration of the chief complaints as regard their onset, duration,
severity, use of medication and progress to be made.

We should also look for any other associated or coexisting problems like

 Abnormal menstrual bleeding

 Amnio pelvic mass
 Pelvic pain
 Any vaginal discharge

History of present pregnancy: the important complications in different trimesters of the present
pregnancy are to be noted carefully. There are hyperemesis and threatened abortions in first
trimester, features of pyelitis in second trimester and anaemia, pre eclampsia and antepartum
haemorrhage in the last trimester. Number of antenatal visits, immunization status has to noted .any
medication or radiation exposure in early pregnancy or medical surgical events during pregnancy
should be enquired.

Obstetric history: this is only related with multigravida. The previous obstetric events are to be
recorded chronologically. To be relevant enquiry is to be made whether she had antenatal and
intranatal care before.

S.NO YEAR & PREGNANCY LABOUR METHOD OF PUERPERIUM BABY:

DATE EVENTS EVENTS DELIVERY
Weight and sex

Condition at birth

Breast feeding

immunization

1 2015 Miscarriage - Evacuation Uneventful -

January at 8 weeks done

2 Baby boy wt-2.6k

2017 july Well covered uneventful Spontaneous uneventful Cried at birth

antenatally vaginal
Breastfed
uneventful delivery
Alive and well

The obstetric history is to be summed up as:

 Status of gravida, parity, number of deliveries (term, preterm), miscarriage, pregnancy termination
(MTP) and living issue G4 (P2+0+1+2) miscarriage-1, living-2.

An undue long gap between the last and the present pregnancy requires careful supervision during
pregnancy and labour. The minimum spacing between first birth and subsequent pregnancy should be 22
years.

Menstrual history: cycle, duration, amount of blood flow are to be noted. It must be remembered that
in certain instances. It may have to be elicited immediately after the presenting complaint. For eg: if a
women presence with menorrhagia, it may be prudent to understand her menstrual history before going
to the history of the presenting complaint. The age of menarche, regularity of menstrual cycle and the
duration of blood flow are important associated features like mid cycle pain or spotting.

Past medical history: relevant history of past medical (urinary tract infections, tuberculosis) is to be
elicited.

Post surgical history: previous surgery general or gynaecological any is to be enquired

Family history: history of conditions that are genetic in origin, familiar or have racial characteristics such
as

 Diabetes in a first degree relative

 Hypertension
 Multiple pregnancies
 Conditions like spina bifida, sickle cell anaemia and thalasemia.

Personal history: contraceptive practice prior to pregnancy, smoking or alcohol habits are to be
enquired.

LMP may be a withdrawal bleed following pill usage. The first ovulation may be delayed for 4-6 weeks

Smoking or alcohol abuse has got some relation with low birth weight of the baby. Previous history of
blood transfusion, corticosteroid therapy, any drug allergy and immunization against tetanus or
prophylactic administration of anti-D immunoglobulin are to be enquired. Lifestyle and exercises also to
be enquired.

Social history: this not only includes living conditions, the diet, employment and access to transport and
healthcare but also her family support and level of education. Certain gynaecological disorders may be
related to the patient’s socio economic status and her present problem may have an impact on her social
life.

Sexual history: in certain circumstances like a women presenting with infertility or requesting
emergency contraception, sexual history may need to be included in the history of presenting complain.

The age of first coitus, frequency of intercourse, presenting of pain ( dyspareunia ) and awareness of
safe sex may need to be inquired , depending on the presenting complaints.
PHYSICAL EXAMINATION

A complete screening physical examination is done during the antenatal period in order to
ascertain whether the women has any medical disease or abnormalities.

It includes a structural review of body systems through observation, inspection, examination and
measurements.

The physical examination should be carried out in an organized manner. As the midwife begins
the procedure, she should be respectful to the client and gentle

The components of physical examination are:

Physical measurement:

 Temperature:
 Pulse:
 Respiration:
 Blood pressure:

General observation and client’s own evaluation:

 Appropriateness of appearance
 Apparent state of health
 Mental and emotional state
 Posture, gait and body movements
 Striking obvious findings such as pallor, cyanosis, or respiratory distress.
 Client’s own evaluation of health, dietary pattern and ability to carry out daily living activities.

General physical examination:

 Build: obese/ average/ thin.

 Nutrition: good/ average/ poor.
 Height: short structure likely to be associated with a small pelvis. Thus in primigravida, the height
is to be measured to screen out the short structure. While an arbitrary measurement of 5 feet is
considered as short structure in western countries. It is 4.7” in India considering the average
height.
 Weight: weight should be taken in an accurate weighing machine. Repeated weight checking in
subsequent visit should preferably be done in the same weighing machine.
 Blood pressure: blood pressure is taken in order to ascertain normality and provide a baseline
reading for comparison throughout pregnancy.
Systolic blood pressure does not alter significantly in pregnancy, but diastolic falls in mid-
pregnancy and rises to near non pregnant level at term. The systolic recording may be falsely
 elevated if a women is nervous or anxious, if a small cuff is used on a large arm, the arm is
unsupported or if the bladder is full.
The women should be comfortably seated or resting in a lateral position on the couch for the
measurement.

Review of systems:

 INTEGUMENTARY SYSTEM: Rashes, moles, lesions, pruritis, bruises, pigmentation, moisture,

scars, tumors and turgor.
 Hair and scalp: general character, scalp infections, lice, dandruff, alopecia and lumps
 Head: headache, dizziness, fainting, sinusitis, involuntary movements
 Eyes: blurring of vision, blind spots in vision, diploplia, photophobia, lacrimation discharge,
redness, burning, glasses or contact lenses, injuries, infection, colour of conjunctiva, papillary size
and reaction to light
 Ears: hearing acuity, ear aches, or discharges, tinnitus, vertigo, infection, mastoid, tenderness,
lesions and placement of head.
 Nose: size, placement, patency of nostrils, epistaxis, discharge, sense of smell and septal
deformity.
 Mouth and throat: conditions of lips, gums, teeth, tongue, and mucosa; sense of taste, voice,
speech, odour of breath, any inflammation or surgery.
 Neck: movement, lymph node enlargement, vein distention, position of trachea.
 Breast: the purpose is to correct the abnormality.
 Nipple: normal, flat or inverted, discharge, skin and granular changes
 GASTHRO INTERSTINAL SYSTEM: appetite, nausea, vomiting, heartburn, belching flatulence,
bowel pattern, haemorrhoids, food allergies, hernias.
 Abdominal examination:
Inspection: abnormal enlargement, pregnancy marks- linea nigra, striae gravidarum, and
surgical scars (midline or suprapubic)
Palpation: to note the height of the fundus.
 In the second trimester, to identify the fetus by external ballottement, fetal movements,
palpation of fetal parts and auscultation of fetal heart sounds.
 In the third trimester, abdominal palpation will help to identify fetal lie, presentation,
position, growth pattern, volume of liquor and also any abnormality.
 Examination also helps to detect whether the presenting part is engaged or not.

CARDIO RESPIRATORY SYSTEM: Breathing pattern, cough, wheezing, infection, respiratory rate, and
rhythm, auscultation findings.

GENITO URINARY SYSTEM: Urination difficulties, and deviations, genital lesions and infections, history of
any hormonal therapy.

MUSCULAR, SKELETAL AND VASCULAR SYSTEM: Status of joints, muscles and extremities, appearance of
nails and fingers.
CENTRAL NERVOUS SYSTEM:

 Speech and memory, complaints of vertigo, convulsions, or loss of consciousness

 Mental status.
 Motor symptoms
 Sensory symptoms

LYMPHATIC AND HEMATO POIETIC SYSTEM: Lymph nodes, bruising tendencies, blood dyscrasias.
OBSTETRICAL EXAMINATION
ABDOMEN:

Abdominal examination is done by these steps

 Inspection
 Palpation
 Percussion
 Auscultation

Tone of the abdominal muscles, presence of any incisional scars or presence of herniation
and skin condition of the abdomen are to be looked for. Fundus of the uterus is just
palpable above the symphysis pubis at 12 weeks

The abdominal examination includes:

 Observation of the uterus, the shape of the uterus, the shape of the uterus, the
contour of the abdominal wall, any scar or injury marks lenia nigra, and straie
gravidarum.
 Determination of lie and presentation, position and variety of fetus.
 Measurement of fundal height, abdominal girth, palpation of fetal position and
auscultation of fetal heart tones.

Each of these items provides informative data useful in diagnosis of frequency,

evaluation of fetal well being and growth and serve as indicators of possible problems.

Inspection:

The examiner’s eyes assess the size of the uterus roughly. A distended colon or
obesity may give a false impression.

Multiple pregnancy or poly hydromnio’s will engage both the length and breadth of
the uterus, where as a large baby increases only the length.

The multiparous uterus lacks the sung avoid shape of the primigravid uterus.
Occasionally it is possible to see the shape of the fetal back or limbs. In posterior position of
the occiput a “saucer like depression” is seen at or below the umbilicus.

The uterus may sag forwards in multiparous women lax abdominal wall. This is
known as pendulous abdomen or anterior obliquity. In the primigravida it is a sign of pelvic
contraction.
 Observation of linea nigra and straie gravidarum are presumptive sign of pregnancy.
Observation or palpation of fetal movements and hearing of fetal heart sounds are possible
signs of pregnancy. The normal range of fetal heart tones is 120-160 per minutes.

Determination of lie, presentation, position are important in pregnancy. By the 36 th

week most babies have settled in to what will be their lie and presentation for the intra
partal period.

This is not absolute, however, as some babies will turn again. Malpresentation prior
to 36 weeks is not a cause for concern because the baby is still turning.

MEASUREMENT OF THE FUNDAL HEIGHT:

It provide information regarding the progressive growth of the fetus as a gross

screening tool for detection of problems related to fundal height, which is too large or too
small for the presumed gestational age by dates.

First method:

It combines knowledge of where to expect the fundal height to be at various weeks of

gestation in relation to the women’s symphysis pubis, umbilicus and tips of xiphoid process
and the use of the examiners finger breadths as the measuring tools.

WEEKS IN GESTATION APPROPRIATE EXPECTED LOCATION OF FUNDAL HEIGHT

 12 weeks  Level of the symphysis pubis

 16 weeks  Halfway between symphysis pubis and umbilicus
 20 weeks  1-2 Finger breadths below the umbilicus
 20-24 weeks  1-2 Finder breadths above the umbilicus.
 28-30 weeks  1/3 of the way between umbilicus and xiphoid process 3
finger breadths above the umbilicus.
 32 weeks  2/3 of the way between the umbilicus and xiphoid process
3-4 finger breadths below the xiphoid process.
 38 weeks  Level of the xiphoid process.

 40 weeks  2-3 finger breadths below the xiphoid process if lightening

occurs.
 In order to determine the height of the fundus the midwife places her hand just
below the xiphisternum pressing gently, she moves her hand gently down the abdomen
until she feels curved upper boarder of the fundus. She notes the number of finger
breadths, which can be comfortably accommodated between two. Though it is a time
honoured method, it has inherent inaccuracies. First there is considerable variation between
women in the distance from their symphysis pubis to their xiphoid process and in the
location of umbilicus between these two points.

There is a considerable variation between the examiners in the width of their fingers
eg: two finger breadths of a thick finger person can be the same as three finger breadths of
a thin fingered person

Second method:

The calliper method of measuring fundal height is probably the most accurate
method of measuring fundal height after the 22-24 wks of gestation.

In order to use calliper or external pelvimeter, place one tip on the superior border
of the symphysis pubis and the other tip at the top of the fundus. Both placements are in
the abdominal midline. The measurement is then read on a centimetre scale located on an
arc close to where two ends of the calliper come together.

The number of centimetres’ should be equal approximately to the week of gestation

after about 22-24 wks of gestation.
Third method:

Measuring fundal height with a tape measure is the most frequently used method
for obtaining an exact measurement. It is probably the second most accurate method of
measuring fundal height after 22-24 wks of gestation.

The zero line of the tape measure is placed on the superior boarder of the symphysis
pubis and the tape measures stretched across the contour of the abdomen to the top of the
fundus. The abdominal midline is used as the line of measurement. In order to avoid error in
locating the superior boarder, you must palpate symphysiass pubis. The number of
centimetres measured should be approximately equal to the weeks of gestation after about
22-24 wks of gestation.
ABDOMINAL PALPATIONS & LEOPOLD’S MANEUVERS:
The term abdominal palpation is often used to mean doing Leopold’s maneuvers for
determining fetal lie, presentation, position and engagement.

The fallowing information is obtained from abdominal palpation

 Evaluation of uterine irritability, tone tenderness, consistency and any contractility

present.
 Evaluation of abdominal muscle tone
 Detection of fundal movements
 Estimation fetal weight
 Determination of fetal lie, presentation, position and variety
 Determination of whether the head is engaged.

LEOPOLD’S MANEUVER:
These are four maneuvers starting at the fundus and ending at the pelvis brim.

PROCEDURE STEPS FINDINGS AND SIGNIFICANCE

FIRST MANEUVER/ FUNDAL PALPATION:
Face the women’s head. Place both hands
on the woman’s fundus and curve the fingers
around the top of the fundus.
Palpate the shape, size, consistency and
mobility of the fetal part in the fundus.
SECOND MANEUVER/ LATERAL PALPATION:
 Continue to face the women’s head. Place
your hands on both sides of the uterus
about midway between the symphysis
pubis and the fundus.
 Fetal parts, that fells around & hard
which are readily movable and
ballotable between fingers of two
hands is indicative of fetal head. The
mobility is due to the head being
able to move independently of the
trunk. The lie is longitudinal.
 Fetal parts that feels irregular, large
or bulkier and less firm that a head
which cannot be readily moved or
balloted, is indicative of fetal breech.
The breech cannot move
independently of the trunk. The lie is
longitudinal.
 If neither of the above is felt in the
fundus, it is indicative of transverse
lie.
 A firm convex continuously smooth
and resistant mass extending from
the breach to the neck is indicative
 of right side of the women’s
abdomen determines the position in
 Apply firm gentle pressure with one hand
a longitudinal lie.
against the side of the uterus, there by
pushing the fetus to the other side of the
 Small knobby, irregular masses
abdomen and with your examining hand,
which move when pressed or may
stabilizing if there. Maintaining pressure
kick or hit your examining hand is
on one side of the uterus with the
indicative of the small parts- hand,
examining hand, palpate the entire area
feet, knees and elbow.
from the abdominal midline to the lateral
side & from the symphysis pubis to the
 These should be felt in the opposite
fundus. Use firm, smooth pressure &
side of the abdomen than the side
rotary movements.
where the back is in.

 Reverse the procedure for examination of

 Small parts all over the abdomen &
the other side of the uterus.
the fetal back difficulty to feel as it
may seem just out of reach in the
posterior portion of the abdomen is
indicative of a posterior position.
THIRD MANEUVER/ PAWLIK
MANEUVER/ SECOND PELVIC GRIP:
 Continue to face the women’s head. Have
her to bend her knees in order to avoid
discomfort during this maneuver.
 A movable mass will be felt in the
 Grasp the portion of the lower abdomen
presenting part is not engaged.
immediately above the symphysispubis
 If the presenting part is the head
between the thumb and middle finger of
that is engaged it may not be rapidly
one of your out stretched hands.
movable.
Press gently in to the abdomen in
order to feel the presenting part below
and between your thumb and finger.
 As in the first maneuver, palpate for size,
shape, consistency and mobility in order
to differentiate if it is the head or breech
in the lower pole of the abdomen.

FOURTH MANEUVER/ PELVIC PALPATIONS/

FIRST PELVIC GRIP:

 Turn and face the women’s feet

 Make sure that the woman’s knees are
 bent to avoid pain during the maneuver.
 Place your hands on the sides of the
uterus with the palms of your hands just
below the level of the umbilicus and your
fingers directed towards the symphysis
pubis.
 Press deeply with your fingertips in to the
lower abdomen and move them towards
the pelvic inlet.
 Continue to move your hands towards
the pelvic inlet.
 Share your findings with the women
 Offer to help her feel and identify various
fetal parts if she would like to..
 If the head is the presenting part,
one of your hands will make contact
with a hard round mass while your
other hand continues in the
direction of the pelvis. This is the
cephalic prominence and if it is on
same side of the women ass the fetal
back, the prominence is the occiput
& indicates face presentation with
the head extended.
 If the cephalic prominence is on tthe
same side of the women as are the
fetal small part, it is the sinciput &
indicates a vertex presentation with
the head well flexed.
If the both hands will encounter
simultaneously a hard mass, which is
equally prominent on both sides, it is
indicative of brow presentation due
to partial flexion of the head.
 At the brim of the pelvis your hands
will converge around the presenting
part with the finger tips of your two
hands touching in the midline
indicating the presenting part is not
engaged, it is above the pelvic brim
or floating.
 If the presenting part is breech, it
will be readily movable.
 The hands will diverge away from
the presenting part and the midline
indicating the presenting part is
either engaged or dipping
 If the presenting part is the breech it
will have a feeling of give along with
the trunk of fetus.
 If you are unable to feel the cephalic
prominence because it is out of
reach in the pelvis, the head is
engaged.
AUSCULTATION:

Auscultation usually from parts of each abdominal examination and fallows any
procedure in order to assess well being. Abdominal palpation determining lie , presentation
and position of the fetus enables you to locate the fetal heart tones.

This is because the sound of the fetal heart is transmitted through the convex
portion of the fetus closest to the anterior uterine wall. Therefore the fetal heart tones aree
best heard through the fetal back in vertex and breech presentation and through the chest
in face presentations. Thus, if you know the position you can readily locate the fetal heart
tones, allowing for some variation fepending on the amount of descend of the fetus in to
the pelvis.

Location of fetal heart tones in various fetal presentation and positional varities:

PRESEBTATION AND POSITIONAL VARIETIES LOCATION

 Cephalic  Midway between umbilicus and level of
anterio superior iliac spine.
 Breech  At the level or above umbilicus
 Anterior  Close to abdominal midline
 Transverse  In lateral abdominal area
 Posterior  in flank area or close to abdominal
midline on otherside of abdomen

VAGINAL EXAMINATION

Vaginal examination is done in the antenatal clinic when the patient attends the clinic for the first
time before 12 weeks. It is done

 To diagnose the pregnancy

 To corroborate the size of the uterus with period of amenorrhea
 To exclude any pelvic pathology

Internal examination is, however, omitted in cases with previous history of miscarriage,occasional
vaginal bleeding is present pregnancy.

Ultrasound examination has replaced routine internal examination. It is more informative and
without any known adverse effect.

Steps of vaginal examination:

Vaginal examination is done in the antenatal clinic. The patient must empty her bladder prior to
examination and is placed in the dorsal position with the thighs flexed along with the buttocks
placed on the foot end of the table. Hands are washed with soap and a sterile glove is put on the
examination hand (usually right).

INSPECTION: By separating the labia using the left two fingers (thumb and index), the character of
the vaginal discharge, if any is noted. Presence of cystocele or uterine prolapse or rectocele is to be
elicited.

SPECULUM EXAMINATION :

This should be done prior to bimanual examination, especially when the smear for exfoliative
cytology or vaginal swab is to be taken. A bivalve speculum is used.

The cervix and the vault of the vagina are inspected with the help of good light source placed
behind. Cervical smear for exfoliative cytology or a vaginal swab from the upper vagina, in presence
of discharge, may be taken.

BIMANUAL EXAMINATION :

Two fingers (index and middle) of the right hand are introduced deep in to the vagina while
separating the labia by left hand. The left hand is now placed suprapubically.

Gentle and systematic examination are to be done to note:

Cervix: consistency, direction and any pathology

Uterus: Size, shape, position and consistency.

Early pregnancy is the best time to correlate accurately uterine size and duration of the
gestation.

Adnexa: any mass felt through the fornix. If the introitus is narrow,one finger may be introduced for
examination. No attempt should be made to assess the pelvis at this stage.

VAGINAL EXAMINATION AT TERM:

The vaginal examination at term is an important procedure to assess progress of cervical

dilation, fetal descent and pelvic adequacy.

STEP 1: Examine the perineal area. Looks for signs of health, intact skin, and signs of inflammation or
infection on perineum.

Note any fluid leaking or bloody show, note any strong odor to fluids, as well as colour and
consistency. Note any scars indicating episiotomy or prior perineal surgery.

STEP 2: Apply sterile lubricating jelly to a sterile latex glove, and part the labia to slip the first two
fingers in to the vagina. Direct fingers to the back of the vagina and move fingers up to contact of the
Cervix.

The opposite hand is placed over the abdomen, Palpating and during a contraction, pushing
down slightly in the direction of the perineum.
 Assess the cervix for the following criteria.

Position: is the cervix directed towards posterior, mid position or anterior

Consistancy: is the cervix firm, medium or soft.

Effacement: recorded as a percentage as fallows.

PERCENTAGE RESULT
Not begun 2 cm long and thick
25% 1.5 cmlong and softened.
50% 1 cm long and very soft
75% 0.5 cm long
100% Feels very thin, ready to be
pulled up in to the lower
uterine segment.

Dilatation: recordedasa range up to 10 cm (fully dilated), measurement is appropriate and depends

on the examiner’s finger size.

DILATATION (Cm) RESULT

Closed or finger tips Cannot insert finger tip in to
canal
2 cm 1 finger width can be inserted
in to canal
3-4 cm 2 finger width
4-5 cm 3 finger width
5-6 cm Finger moves easily from side
to side of fetal presenting part
before touching cervix
7-8 cm Cervix is felt like a low smooth
ridge surrounding the curve of
the presenting part

8-9 cm Ridge of encircling cervix is

stretched taut, with more
vaginal bleeding as capillaries
are broken in cervix
9-10 cm Cervix flat, almost pulled up
around presenting part, may
still be felt as an anterior or
posterior rim or lip
Complete Cervix cannot be felt as fetal
parts slips through, enters
vagina descends through
stations.
Station: assess the level of descent of the presenting part by locating the ischial spines on either side
of the canal, and assessing the relative location of the fetal parts to these spines.

STEP 3:

Explain findings to women and make her comfortable after examination completed.

SPECIAL INVESTIGATIONS

Serological tests for rubella, hepatitis B virus and HIV: Antibiotics to detect rubella immunity and
screening for hepatitis B virus and HIV

Genetic screening : Maternal serum alpha fetoprotein (MSAFP) : Triple test at 15-18 weeks for
mother at risk of carrying a fetus with neural tube defects, Down’s syndrome or other chromosomal
abnormalities

Ultrasound examination : first trimester scan: Either Trans abdominal (TAS) helps to detect:

 Early pregnancy
 Accurate dating
 Number of fetuses
 Gross fetal anomalies
Use of ultrasound should be selective rather than a routine

Booking (18-20 wks) scan: has got advantages in addition to first trimester scan:

 Detailed fetal anatomy survey and to detect any structural abnormality include cardiac
 Placental localozation
Ultrasound examination is performed as a routine at 18-20 weeks though doubt remain
about its absolute benefit.

Repetition of the investigation :

 Hemoglobin examination is repeated at 28 and 36 th week

 Urine is tested for protein and sugar at every antenatal visit.