History and Physical Examination of A Pregnant Woman - Principles of ANC

Lecture notes -Antenatal care 1
Antenatal Care
Obstetric evaluation and
principles of ANC
Department of Obstetrics & Gynaecology
Standardised lecture MBCHB 3
Lecture 2
Pregnancy is the only condition in humans that prompt

women to attend to a health facility for reasons other than
being sick and therefore provide a window of opportunity
to do a health screen well before onset of disease. There is
an onus on the health practitioner to identify and
minimise potential risk as there is an unrealistic
expectation from parents to be (and grandparents to be)
that there will be a perfect outcome.
1
Purpose of this lecture

• Understand basic concepts of antenatal care
• Understand assessment of the pregnant woman
• Accurately determine gestational age
• Initial screening and risk identification
• Understand the South African ANC context
By the end of this lecture you should have a basic

understanding of the purpose of antenatal care and how
to assess a pregnancy to identify potential risks through a
structured history and physical examination and principals
of pregnancy care as expected from the South African
context
2
PURPOSE OF ANC
Attempt through antenatal preparation best possible
pregnancy outcome for Mom & Baby
• Screening for pregnancy problems
• Assessment of potential risk
• Treat problems that may arise during pregnancy
• Provide information to the mother
• Prepare mother for childbirth and parenthood
New mothers are both excited and scared and need some
reassurance and proper information regarding the
pregnancy, any potential risks and information to support
them in the preparation to child birth and parenthood.
They are also bombarded with various sources of
information from social media, magazines and the internet
if they are fortunate to have access to these resources or
are alternatively ignorant about pregnancy and subjected
to gossip and common opinions
3
2018 mortality comparison

under
Late
C/S iMMR SB Rate 2500g at early NND NNMR
NND
birth
Eastern Cape 30,0 113,1 18,7 13,7 10,8 2,0 12,8
Free State 30,9 167,6 26,4 13,6 13,4 2,9 16,3
Gauteng 28,7 120,8 19,2 13,5 9,8 3,3 13,1
KwaZulu-Natal 32,4 86,8 22,0 12,0 8,9 2,3 11,2
Limpopo 21,1 109,3 20,8 10,7 11,6 1,5 13,0
Mpumalanga 22,0 116,9 20,6 11,7 10,6 1,5 12,1
Northern Cape 22,0 64,5 24,9 18,0 9,2 1,4 10,6
North West 25,8 156,2 22,0 13,9 8,5 1,7 10,2
Western Cape 29,3 65,2 18,9 14,3 7,0 1,7 8,7
South Africa 27,9 108,6 20,7 12,9 9,8 2,2 12,0
Risks for poor pregnancy outcomes is real, and my vary

according where the patient stay. As you can see in this
mortality comparison, residing in our province and using
our health system already place the women at higher risk
for maternal deaths, still births and neonatal deaths
compared to other areas in the country and therefore
emphasises the importance of quality antenatal care and
early identification of risk. This information is in contrast to
the world health organisation earlier thinking that 3-4
antenatal visits was cheaper and as effective as multiple
assessments- an concept dubbed as basic antenatal care
4
What is BANC Plus

• 2016 WHO antenatal model
• Increase the number of BANC visits to 8 (booking plus 7 (BANC+))
evidence based
• Booking (<12 weeks)
• 20 weeks (ultrasound scan for LMIC)
• 26, 30, 34, 36, 38, 40 weeks (focus on third trimester)
International standards for antenatal care was published

by the World Health organisation suggesting that limited
number of antenatal care assessments have a similar
outcome to multiple assessments. This was however
revised recently to increase the number of visits to at least
8 with more focus on 3rd trimester visits – the model was
renamed basic antenatal care PLUS and includes an
ultrasound assessment at 20 weeks and more regular
assessments in the later half of the pregnancy
5
Why BANC Plus

MPUMALANGA AUDIT( BANC MODEL)
• Most common cause of stillbirths
• Hypertensive disorders
• Unexplained (IUGR)
• Third trimester- greatest risk
Research informed the decision as there was an increase in

stillbirths due to hypertension and intrauterine growth
restriction in the last trimester therefore identifying the
last trimester as the period of greatest risk
6
Why BANC Plus

Mpumalanga audit (BANC model)
• Modifiable factors
• Failure to measure or respond
to maternal hypertension
• Poor knowledge and skills
• Delay in referral to expert care
• Failure to detect risk factors
Common factors implied in these deaths (often referred to

as modifiable factors) include poor knowledge and
inability to identify risk, failure to respond to risks
(especially appropriate management of maternal
hypertension and health personnel not knowing the
limitations to their own ability) and therefore refer women
late to appropriate specialists
7
Why BANC Plus
The South African analysis of perinatal deaths highlighted

factors associated with poor outcomes. It is important to
note that many factors are associated with actions and
skills related to medical personnel.
This includes issues such as delay in referring, not
responding to identified problems and incorrect
management of known conditions.
I have highlighted this so you can understand that a proper

antenatal assessment will assist in identifying risks and
that you need to develop the skills to identify problems or
risks in the pregnancy to improve on outcomes.
8
Effective Interventions During The

Antenatal Period.
Problem Prevention Screen/diagnose Treatment
HIV As for STIs Counselling and Antiretroviral therapy for

voluntary testing mother, PMTCT for
fetus/neonate
Multivitamin
supplementation
Tuberculosis TB prophylaxis where History, GeneXpert, Anti TB drugs
indicated Chest X ray, sputum
culture
Malaria Prophylaxis Symptomatic treatment Anti malarial drugs
Pre-existing medical History and Refer

conditions, Diabetes, examination
heart disease, epilepsy
Gestational diabetes Family history, previous Investigate,

mellitus baby’s birth weights, Treat as necessary or
Glucosuria, ↑ BMI refer
Malnutrition Balanced protein/calorie History, clinical Refer social workers,
supplementation, examination Food supplementation
multivitamin
(Body/mass index,
supplementation
UMAC)
There are a number of effective interventions identified

that can be identified and assist in preventing adverse
outcomes. This can include conditions affecting both the
mother and fetus such as infections, medical conditions
and malnutrition. In our province HIV, tuberculosis
gestational diabetes and malnutrition are important
conditions.
9
Effective Interventions During The

Antenatal Period.
Mother
Anaemia Iron and folate Check Iron and folate or

prophylaxis haemoglobin iron injections or
blood transfusion
Hypertension/pre- Calcium Check blood Treat hypertension

eclampsia supplementation pressure, urine
Syphilis As for STIs RPR, VDRL Bicillin
Vaginitis As for STIs Syndromic Erythromycin and

approach metronidazole
Urinary tract Personal hygiene Urine dipsticks or Ampicillin

infection urine culture
The screening and prevention of maternal complications

are well described including anaemia, infections and
pregnancy induced hypertension
10
Effective Interventions During

The Antenatal Period.
Fetus
Poor fetal growth Balanced protein/calorie Uterine growth (serial Timely delivery
supplementation, symphysis-fundus
Advice on smoking
measurements)
Post-maturity Accurate gestational Calculate gestational Induce labour at 41
age age weeks gestation
Multiple pregnancies Careful assisted Uterine growth, Refer
reproduction Sonar
Breech presentation Uterine palpation External cephalic version/
Caesarean section
Congenital Pre- and Peri-conception folic Maternal age, previous history, Refer to specialists
acid supplementation, Uterine growth, Sonar
abnormalities abnormalities
Advice on alcohol consumption
Rhesus Anti –D prophylaxis for Rapid Rh, Coombs test Refer Rhesus negative
isoimmunisation Rh negative women in for Rh negative women women with anti-D
previous pregnancy antibodies
Neonatal tetanus Tetanus Toxoid
immunisation
There are also a number of fetal risks that can be screened

for to prevent or minimise adverse outcomes
These preventative measures emphasise the importance

of proper antenatal care in the reduction of pregnancy
related risks
11
Pre-conception care
• Optimise health or knowledge before pregnancy
• Important for any medical conditions
• Previous poor pregnancy outcomes
• Family history or genetic risk
• Socio economic or family issues
• Mental health issues
Whenever you are in general practice, it is important to

understand that the care already start prior to conception
and where you have women of reproductive age with risk
or who intend to fall pregnant, it is important to identify
potential risk factors, and where possible optimise the
factors prior to conception. Listed here are the important
aspects that you should always be aware of and manage in
women of reproductive age
12
All women child bearing age need

to know
• Chromosomal abnormality risk increase with age
• Risks associated with alcohol and other recreational drugs
• Family history of genetic disorders increase risk
• Risks associated with medical conditions
• Risks of maternal infections to the fetus
• Fetal risks in mother taking teratogenic drugs
Create a setup where you can appropriately inform women

of common risks , especially those that can be avoided,
and those that women must become aware of increased
risk of genetic abnormalities associated with age and
family history of genetic disorders so parents can take an
appropriately informed decision when deciding on
pregnancy.
13
Confirm pregnancy
• As early possible
• Provide Antenatal card
• Complete gestational
assessment
It is in the woman’s best interest to confirm the pregnancy

as early as possible as this greatly improve the accuracy of
the gestational age. There is a tendency among women,
especially in the more rural areas, to confirm pregnancy
early with a GP, but only report to the clinic for antenatal
care in the second half of the pregnancy when the
pregnancy becomes visible. This delays the identification
of risk and is associated with an increase in the incidence
of adverse outcomes. As a doctor you need to do a proper
risk assessment as early as possible and make use of the
standardised National Maternity Case Record book, to
document the initial assessment and screening for
potential risk.
14
FIRST ANTENATAL VISIT

• Determine gestational age
• Detailed history and physical examination
• Identify risk factors
• Initiate routine screening tests
• Structured antenatal card assist in checking all the main issues
The first encounter with a health worker during pregnancy

is an important event. This is referred to as the FIRST visit
and is important to do a thorough history and physical
assessment and initiate screening tests to identify
potential risks. An important part of the first visit is to
determine the current gestational age and the potential
date of delivery.
All health professionals should know the structured format
of the history, examination and routine screening
processes.
In South Africa this process have been standardised and is
published in the National maternity case record book. A
copy of the latest maternity care record is uploaded on
Blackboard for your perusal. You may find that at some
15
facilities earlier versions are still in use.
15
SA ID Number
Birth companion
Mandate
There are 3 important aspects you need to pay attention

to on the cover page of the Maternity case record book
1. The ID number (or passport number for foreigners) This
is important to ensure that the baby can be registered
after birth, and if the woman is not in possession of an
ID document, she must urgently apply for one at the
department of home affairs, otherwise the baby cannot
be registered
2. The name and contact number of her birth companion.
It is important for women to identify an trusted person
to accompany her during the labour process. This may
be the spouse, but could be her mother or a trusted
close friend. This discussion should start at the first visit
and she should be informed of the advantages of a
16
supporting companion
3. Her MANDATE. According the national health act, no
treatment may be given without the user’s informed
consent. Users must mandate a person in writing to give
consent on their behalf should they not be in a position
to do so. Pregnancy may be associated with
complications that may rewire a mandate to assist in
decisions and this must be done in writing as early in the
pregnancy as possible
16
The structured antenatal assessment contains all the

important elements that you must be able to enquire and
assess during the first visit are listed on the form. This
should also form the basis your clinical assessments of
pregnant women. In your initial study of obstetrics, you
may be overwhelmed by the vast volume of information in
the prescribed text books, but those listed here are the
important issues to concentrate on.
It is also important that the health worker responsible for
the first visit need to be identified and introduced to the
woman
17
Obstetric History
Previous obstetric history is important, and all women are

described in the GPM format. The following is important
terminology: Gravida refers to the numbers of pregnancies
irrespective of duration or outcome and is referred to as a
G followed by a number. Para refers to the number of
viable pregnancies that delivered irrespective of the
outcome of the baby and is noted as a P followed by a
number. Non-viable pregnancies (22weeks or less than
500g) is referred to as a miscarriage and noted as a M
followed by a number. Therefore a primigradida during her
pregnancy will be referred to as a G1P0M0
and after the delivery as a G1P1M0.
If she was pregnant before we need to capture the year of
ending the pregnancy including the gestational age at time
18
of delivery, delivery method, birth weight and sex and the

outcome of the pregnancy.
Any complications that were encountered during the
pregnancy or delivery should also be documented. This will
give you a sense of recurrence risk to either the mother or
the baby
18
This is followed by a general history including medical and

surgical conditions and a family history. The important
broad topics are blocked to allow you to tick the common
conditions, but if there is anything else, this should also be
documented. The blocked conditions is must-know topics
and should be the ones during the obstetric course that
you should concentrate on . It is also important to
document any medications she should be using, either
prescribed or over-the counter medications
You will note emphasis on screening for potential
tuberculosis symptoms.
19
The detailed history is followed by a physical examination

documenting the standard organ systems. Blood pressure
reading must be recorded, and ideally the pulse rate as
well.
It is important to assess the thyroid breasts and
cardiopulmonary systems. Any murmurs of signs of
cardiopulmonary abnormalities must be taken seriously.
I will cover more detail of the abdominal examination later
in the presentation.
Vaginal examination may be required in early pregnancy or
when premature onset of labour is suspected.
It is important to document the height of the woman and

the weight as early as possible in the pregnancy to
20
calculate her body-mass index. Where weighing is a

problem the mid-upper-arm circumference (MUAC) may be
used
20
There is a good correlation between the BMI and the mid-

upper-arm circumference throughout the pregnancy and
MUAC measurements of > 30cm suggest that the woman
is obese or morbidly obese. BMI should be done early in
pregnancy because with an increase in the uterus, the
later calculations becomes inaccurate
21
All pregnant women need an abdominal examination.

Ideally the symphysis-fundal height must be measured and
recorded. If measurement are not possible, abdominal
landmarks can be used to estimate pregnancy duration
The pregnant uterus becomes an abdominal organ at
around 11-12 weeks of gestation. Mid-way during the
pregnancy the uterus is palpable at the level of the
umbilicus. Pregnancies with a uterus palpable below the
umbilicus is non-viable unless there is severe intrauterine
growth retardation.
The best way to determine the size of the uterus is
measuring the uterus with a simple measuring tape
between the symphysis pubis and the highest part of the
uterus
22
Measuring The SFH
• Mark the highest point of the

fundus with with a ball-point
pen (ask for permission first)
• Do not correct dextroversion
of the uterus or exert
pressure on the fundus
The abdomen is soft and can easily be compressed-

therefore it may be important to mark the highest point on
the skin without correcting dextroversion of the uterus to
avoid large variations in measurements
23
Measuring The SFH

• Fix the zero of the tape
measure at the top of the
symphysis and stretch the
tape over the curve of the
uterus up to the pen mark
• Read the measurement to
nearest cm
Measure the distance from the top of the symphysis

without exerting pressure to the highest point up to the
pen mark, rounding the measurement to the nearest
centimeter
24
After documenting the uterine size, you need to describe

the lie in the advanced pregnancies, especially beyond 30
weeks. The lie can either be longitudinal, oblique or
transverse. If the lie is longitudinal, the presenting part
should be a fetal head, but may also be a breech
presentation
25
You need to be able to describe the uterine content

referring to the Lie, Presenting part and, where a vertex
presents, the extent of flexion and head above brim.
The Leopold manoeuvres should be used as an

assessment tool to evaluate detail of an advanced
pregnancy with the abdominal examination. There are 4
manoeuvres described and a video demonstrating the
manoeuvres have been uploaded for your perusal. During
the clinical assessment you will be expected to describe
the detail of the abdominal examination according the
manoeuvres. The first maneuverer is aimed at determining
the size and content to the upper uterus. The second is to
determine the lie of the fetus and which side is the back,
26
The 3rd determine the content and descent of the lower

part of the uterus and the 4th maneuverer determine if the
head is engaged and the extent of flexion of the presenting
part
26
The important laboratory and side-room investigations are

tabulated under investigations. This summarises all the
National standard screening tests and you must regard
these conditions as important must=know topics. This
includes screening for syphilis, Rh factor, anaemia and HIV
status.
.
27
The most important aspect of the first visit is that you

need to determine, to the best of your ability and available
information, the current gestational age and the
estimated date of delivery. Not only is this important for
risk identification, but also to advise the patient when to
be ready for the delivery process.
The important information you need to obtain is the date
of the last normal menstrual period, and if the woman is
certain of that information. The earlier in the pregnancy
this information could be obtained, the easier it is for the
woman to remember
28
How to determine gestational age
• Dates are known and likely to be accurate

• Unknown dates
• Discrepancy between dates and uterine size
There are 3 main methods that could be used assist in

determining the gestational age. This is based on accurate
knowledge of menstrual dates and the correlation
between the uterine size and the dates
29
If the dates are known and likely to be accurate, it is

relative easy to calculate the gestational age and estimate
the timing of delivery. Various APPS are available that
could be downloaded and are often based on the obstetric
wheel.
If this is not available to you, you may use Negele's
formula to calculate the estimated date of delivery : Add 7
days to the first day of the LMP then subtract 3 months
30
The obstetric wheel is an easy way to calculate the

expected date of delivery based on the first day of the last
period. More importantly it will provide you with the
weeks of gestation at a specific date and you can therefore
accurately determine the gestation age at the time of the
assessment. The inner part of the wheel can rotate
allowing to set the date according the LNM, but you can
also set the gestational age where that is known, e.g
through an ultrasound.
Note the probable date of birth at 40 weeks with a range
between 37 and 42 weeks. It is therefore wise to give the
woman a range when to expect the baby- I often say I
would be worried if the baby arrive before a certain date
of have not delivered by a certain date
31
How to determine gestational age
• Dates are known to be accurate

• Unknown dates
• Discrepancy between dates and uterine size
The LNM cannot be used if it is unknown. Therefore

other methods should be used. In the first trimester a
vaginal examination may give the proximate size of the
uterus. Remember the uterus is palpable at the symphysis
pubis around 12 weeks of gestation.
Measuring the size of the uterus in cm may be of
assistance to estimate the gestational age
32
Step 1
Here we use the SF measurements and then plot the

measurements against the pregnancy progress graph. The
first step is to measure the uterus with a tape measure
and then see where it cross the 50th centile of the uterine
growth curve. The upper line represents the 90th centile
and the lower line the 10th centile
33
Step 2
Step 1
The second step is to follow the line vertical to the

gestational age- in this case the uterus measured 26 cm
and cross the 50th centile at 27 weeks of gestation. We will
therefore conclude she is 27 weeks pregnant. Please note
however, if we take the gestations where the horizontal
line (uterus size) cross the 90th and 10th centile lines, we
again have a range of between 24 and 29 weeks gestation.
The important issue will be that henceforth the uterine
growth should follow the normal growth curve.
34
Ultrasound
• Ultrasound does NOT
measure gestational age
• Only the size of the fetus
• US for gestation more

accurate in early
pregnancy
Ultrasound can also assist to determine the gestational

age. It is important to note that an ultrasound cannot
measure age, but only the size of the fetus. Because
growth is more rapid in early pregnancy the
measurements are more accurate and the margin of error
less than in late pregnancy
The ultrasound computer calculate the average gestational
age of a fetus with the size as measures
35
Ultrasound computers calculate the gestational age based

on the averages of various measurements. As human
beings of the same age may differ significantly in size,
there is a range in gestational age as the calculated value
reflect the mean age of a fetus of the measured size
36
Due to the rapid growth in early pregnancy, ultrasound

performed in early pregnancy is more accurate and
within the first trimester will be accurate within 3-5 days,
but in late pregnancy can be only within 2-4 weeks.
Whenever you calculate the gestational age, it is important

that you document the method used to calculate the
gestational age
37
Besides screening for metal health issues, there is a

checklist of topics that need to be discussed with the
woman during pregnancy, especially feeding and parental
preparedness, danger signs in pregnancy and self
monitoring of fetal movements. It is also important to
discuss the future family planning after completion of the
pregnancy and to obtain consent for surgical methods
before onset of labour after good quality informed consent
38
Mental distress screen
In the last 2 weeks, have you on some or most days felt unable to stop
☐Yes (1) ☐No (0)
worrying or thinking too much?
In the last 2 weeks, have you on some or most days felt down, depressed
☐Yes (1) ☐No (0)
or hopeless?
In the last 2 weeks, have you on some or most days had thoughts and
plans to harm yourself or commit suicide? (The self harm question will
require urgent referral if there are both thoughts AND plans. If there is a ☐Yes (1) ☐No (0)
history of previous attempt, referral is required even if there are thoughts
alone.)
☐0
☐1
TOTAL SCORE
☐ 2 > Refer
☐ 3 > Refer
It is suggested that routine a 3 question mental distress

screen be applied to identify women at risk. It must
however be emphasised that this should be performed if
there are resources available to refer those identified. This
tool however assist to create awareness of the mental
status of pregnant women.
39
Essential information for all

pregnant women
• Danger signs/symptoms in pregnancy
• Severe headache
• Abdominal pain (not discomfort)
• Drainage of fluid from vagina
• Vaginal bleeding
• Reduced fetal movements
Any of these symptoms must be reported immediately
It will be important to discuss the typical danger signs with

the patient and inform her that she need to immediately
report to you, or the closest health professional, should
any of them develop, and not wait until the next
scheduled consultation to complain about them
40

pregnant women
• Self care in pregnancy
• Diet and exercise
• Personal hygiene and breast care
• Use of any medication
• Use of alcohol, tobacco or recreational drugs
Women are often ignorant around personal self care

during pregnancy and will need some advice or an
information brochure to inform them of hygiene and
dietary aspects
41

pregnant women
• DELIVERY PLAN
• Expected date of delivery based on best estimate
• Expected place of delivery
• Expected mode of delivery
• Who will deliver the baby
• Pain relief during labour
• Transport plan to labour ward including emergency
numbers
Take time to discuss with the patient the delivery plan that
includes where to deliver by whom and what pain relief
options would be available. They need to be made aware
of their responsibility to ensure that they have made
arrangements to travel to the delivery site when they
suspect onset of labour or at least have the emergency
numbers of transport services. Some failures develop
because they do not arrive in time and deliver at home or
en route to the hospital. Should access be a problem,
especially in the deep rural poor communities, availability
of a maternity waiting home should be discussed as a
possible solution
42

pregnant women
• New born and infant care
• Plans for feeding the baby
• Follow-up care
• Future pregnancy and contraception
• Information on genetic disorders and birth defects
The mother-baby-pair feeding and follow-up also need to

be clear to the expectant mother. This should also assist
you to identify the potential at-risk mother baby pair
before delivery to assist in your postnatal planning
43
Any YES – not eligible for BANC

Need specialised referral follow-up
All department of health clinics at PHC have these

checklists to assist to identify where follow-up should take
place. If any of the risk factors was detected with the
checklist – then the mother should not be cared for at
primary care level and will need to be referred for
specialised follow-up
44
ANTENATAL FOLLOW-UP
• Ask, check antenatal record
• Look, listen, feel
• Record signs
• Classify
• Treat and advise
• Every woman should receive or be checked at every visit:
• Iron, folate and calcium (and multivitamins if indicated)
• Nutritional advice
• Advice on what to do if the warning signs in pregnancy appear
• Where she plans to give birth
• What transport arrangements have been made should she go into labour
• Complete antenatal record and clinic checklist
• Make arrangements for the next visit
Follow-up visits will not require the intense scrutiny of the

first visit, but a reassessment to screen for developing
risks. The Principles of antenatal follow-up and assessment
of fetal well being will be discussed during a next lecture
45
Dates in chronological order
UTERUS BIGGER THAN

EXPECTED
UTERUS SMALLER
THAN EXPECTED
To be able to identify risks, you must develop the skill to

compile an appropriate problem list. Many of the
pregnancy failures are linked to the inability to compile a
problem list and to determine potential risk
46
The maternity case record books also make provisioning

for additional detail that can be documented during
follow-up visits. As new problems arise during pregnancy,
it must be added to the problem list and the potential risk
be revised
47
Risk factors requiring specialist/

hospital referral
Obstetric history
• Previous stillbirth
• Previous neonatal death
• Previous low birth weight baby (<2.5 kg)
• Previous large baby (>4.5 kg)
• Previous pregnancy admission for hypertension or pre-eclampsia/eclampsia
• Previous caesarean section
• Previous myomectomy
• Previous cone biopsy
• Previous cervical cerclage
As doctors that will be working in the primary health care

setting, it is important that you will be able to identify risk
factors that will require referring the patient to a specialist
centre or referral hospital . Here are some of the
important factors that can be detected through the
obstetric history
48
Risk factors
Current pregnancy
• Diagnosed or suspected multiple pregnancy
• Age <16 years Age ≥37 years
• Rhesus isoimmunisation in previous or current pregnancy
• Vaginal bleeding
• Pelvic mass
Blood pressure > 140/90 mm Hg
Multiple pregnancies and pregnancies complicated with

hypertension or vaginal bleeding need to be referred for
opinion
49
Risk factors
Current pregnancy
• Diabetes mellitus
• Cardiac disease
• Kidney disease
• Epilepsy
• Asthma on medication
• Active tuberculosis
• Known substance abuse including alcohol
• Any severe medical condition
Medical conditions are all highly specialised in nature and

need to be managed by the best skills available.
50
Risk factors
Factors requiring hospital delivery
• Previous postpartum haemorrhage
• Parity ≥5
Some factors are a risk during delivery and need to be

referred for confinement once in labour
51
Risk factors
Factors Arising during antenatal Care
• Anaemia not responding to iron tablets
• Uterus large for dates (>90th centile symphysis-fundal height)
• Uterus small for dates (<10th centile symphysis-fundal height)
• Symphysis-fundal height decreasing below 10th centile
• Breech or transverse lie at term
• Extensive vulval warts that may obstruct vaginal delivery
• Pregnancy beyond 41 weeks
• Abnormal glucose screening (GTT or random blood sugar)
• Reduced fetal movements after 28 weeks
With follow-up of antenatal care, a number of risks can be

identified that will result in change of strategy. This will
be referred to in more detail in the lecture on antenatal
follow-up and fetal well being lecture
52
Problem identification and

assessment
• Jot down all the findings from the history and examination that is
outside the limits of normal
• Establish a list of causes linked to the list of abnormalities
• Common things occur commonly, don’t forget the rarities
• Draft a list of special investigations that will allow you to differntiae
between the various possibilities
The core skill that you need to develop is how to compile a

problem list from your assessment of the patient including
the history and physical examination and be able to link
this with probable causes and identify what additional
investigations are needed to differentiate between
different possibilities
53
The maternity case record book has a page to allow you to

document a detailed initial assessment that will prompt
the differential diagnosis, diagnostic and treatment plan
54
Summary
•Need to understand the ability to determine

gestational age and estimated date of delivery
•Need to identify and refer at risk pregnancies
•Need to extensively counsel pregnant women
To summarise this complex lecture. In all pregnancies you

need to be able to determine the gestational age, identify
and refer the at risk pregnancies and be able to
extensively counsel the pregnant woman on a range of
important topics and risks.
55
Thank you
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History and Physical Examination of A Pregnant Woman - Principles of ANC

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History and Physical Examination of A Pregnant Woman - Principles of ANC

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Lecture notes -Antenatal care 1

Pregnancy is the only condition in humans that prompt

Purpose of this lecture

By the end of this lecture you should have a basic

2018 mortality comparison

Risks for poor pregnancy outcomes is real, and my vary

What is BANC Plus

International standards for antenatal care was published

Why BANC Plus

• Third trimester- greatest risk

Research informed the decision as there was an increase in

Why BANC Plus

Common factors implied in these deaths (often referred to

Why BANC Plus

The South African analysis of perinatal deaths highlighted

I have highlighted this so you can understand that a proper

Effective Interventions During The

HIV As for STIs Counselling and Antiretroviral therapy for

Pre-existing medical History and Refer

Gestational diabetes Family history, previous Investigate,

There are a number of effective interventions identified

Effective Interventions During The

Anaemia Iron and folate Check Iron and folate or

Hypertension/pre- Calcium Check blood Treat hypertension

Syphilis As for STIs RPR, VDRL Bicillin

Vaginitis As for STIs Syndromic Erythromycin and

Urinary tract Personal hygiene Urine dipsticks or Ampicillin

The screening and prevention of maternal complications

Effective Interventions During

There are also a number of fetal risks that can be screened

These preventative measures emphasise the importance

Whenever you are in general practice, it is important to

All women child bearing age need

Create a setup where you can appropriately inform women

It is in the woman’s best interest to confirm the pregnancy

FIRST ANTENATAL VISIT

• Structured antenatal card assist in checking all the main issues

The first encounter with a health worker during pregnancy

facilities earlier versions are still in use.

There are 3 important aspects you need to pay attention

The structured antenatal assessment contains all the

Previous obstetric history is important, and all women are

of delivery, delivery method, birth weight and sex and the

This is followed by a general history including medical and

The detailed history is followed by a physical examination

It is important to document the height of the woman and

calculate her body-mass index. Where weighing is a

There is a good correlation between the BMI and the mid-

All pregnant women need an abdominal examination.

Measuring The SFH

• Mark the highest point of the

The abdomen is soft and can easily be compressed-

Measuring The SFH

Measure the distance from the top of the symphysis

After documenting the uterine size, you need to describe

You need to be able to describe the uterine content

The Leopold manoeuvres should be used as an

The 3rd determine the content and descent of the lower

The important laboratory and side-room investigations are

The most important aspect of the first visit is that you

How to determine gestational age

• Dates are known and likely to be accurate

There are 3 main methods that could be used assist in