ANTENATAL CASE SHEET

Ms _ _ _, a _ _ _ yr. old female, resident of _ _ _, who is a _ _ _ by occupation, educated

upto _ _ _ and is married to Mr _ _ _, a _ _ _ by occupation for the last _ _ _ yrs. Pt. is a
primigravida/gravida _ _ _ (with previous _ _ term/preterm/abortion), with _ _ _
months period of gestation and she presented with the

Chief Complaint(s) of:

I) __________________________________ X ____________________
II) __________________________________ X ____________________

If patient does not have any chief complaints, mention negative history of Bleeding,
Leaking, Pain abdomen, Back ache, Foetal movements adequacy.

HOPI:

1. Elaborate the chief complaints (onset, duration, progression, severity, radiation,

aggravating and relieving factors etc.)
2. Comment on sleep, appetite, bowel and bladder habits
3. Finally comment on foetal movements

H/O present pregnancy:

1. Booking status (when), JSY benefits (±registered)

2. Pt conceived _ _ _ yrs. after her marriage/Last Child Birth
3. Planned/unplanned conception; spontaneous/conceived after treatment of
infertility/contraception failure
4. Weight at preconception period (if known)
5. Did she start preconception Folic Acid?
6. When was her first antenatal visit

FIRST TRIMESTER

1. How was the pregnancy confirmed?

2. USG scan done (when) or not
3. Is she taking Folic Acid
4. Nausea, Vomiting
5. H/o of hospital admission (Why, how long, treatment received)
 6. Any other drug intake
7. Fever with rash (at last)
8. Radiation exposure
9. Any other complications e.g.
Bleeding/spotting, medical or surgical problems

SECOND TRIMESTER
1. Is she on regular antenatal check up
2. Quickening (when)
3. Is she taking Tab Iron / Calcium
4. Level II sonography (Targeted anomaly scan)
5. Has she been immunised with TT
6. Weight gain in second trimester (if known)
7. Any other complications e.g.
Bleeding, UTI, anaemia (palpitations, fatigue), deranged sugar level, severe
headache, blurring of vision, decreased urine output, other medical or surgical
problems

THIRD TRIMESTER

1. Is she on regular antenatal check up

2. Foetal movements (decreased/absent)
3. Lightening (when)
4. Pain abdomen
5. Bleeding/Leaking
6. Weight gain in third trimester (if known)
7. Any other complications e.g. –
Severe headache, blurring of vision, gen swelling of body, decreased urine
output, UTI, anaemia (palpitations, fatigue), other medical or surgical problems

Obstetrics History:

G_ P T_P_A_L_ LCB: _ _ _ yrs. back

1. In case of Primigravida - write Primigravida

2. In case of Multigravida, previous obstetrics events are to be recorded chronologically
as follows:
S.No. Date/Year Antenatal Labour Place of Method of Baby at birth Puerperium
period events delivery delivery
Wt. & Sex
Cried at birth
APGAR score
Breast fed
Immunisation

Menstrual History:

LMP –
POG –
EDD –

PREVIOUS MENSTRUAL CYCLE:

Age of menarche -
Cycle length -
Duration -
Amount of flow -
Passage of clots -

Past history:

Medical: HTN, DM, TB, Asthma, Epilepsy, STD, HIV/AIDS, Heart disease, Bleeding
Problems, Drug intake, Blood transfusion, any h/o hospitalisation
Surgical:
General surgical : appendectomy, cholecystectomy, any other surgery
Gynaecological : D&C, myomectomy, fistula repair

Treatment history:

Personal History:

Diet (veg/non-veg), appetite, sleep, bladder, bowel, contraceptive practice prior to

pregnancy, smoking or alcohol habit, allergy
Family History:

Type of family, No. of family members, significant events last year, social relations,
stress in family, legal issues, taboos/stigmas
Any h/o DM, HTN, TB, blood dyscrasia, known hereditary disease, h/o of twining in
family.
Examination -
1) Consent
Socio-economic history: 2) Evacuate bladder
3) Positioning of pt.
Total income : 4) Stand on Rt side of pt.
SE status :
Inspection - 1)Uterine ovoid -
Longitudinal/Transverse/Oblique
2) Contour of uterus
-----------------------------------------------------------------------------------------------------------------
3) Skin condition - Linea nigra & Striae gravidarum
4) Scar mark/Incisional mark
DIAGNOSIS: Palpation - 1) Ht of uterus with ulnar border of hand
Ms _ _ _ is a _ _ _ yr. old primigravida/multigravida with _ _ _ weeks’ gestation (with
anaemia/HTN/past h/o of abortion).

Grips/Leopold maneuver -
1) Fundal grip - Smooth hard mass
suggestive of Head.
Broad soft & irregular mass suggestive of
beech

2) Lateral/Umbilical grip - To find position of

back,limbs and Anterior shoulder

3)Paulik's grip - Keep ulnar border of palm on

symphysis pubis & overstretched thumb and
four fingers of Rt. Hand are placed over lower
pole of uterus .

4)Pelvic grip - Done facing patient's feet.

4 fingers of both hands are placed on either
side of midline in lower pole of uterus and
parallel to the inguinal ligament.