Checklist for Examination in Pregnant Women

PHYSICAL EXAMINATION
General Examination (Every Visit)
1. Observe her general well-being:
• Her gait and movements (walks steadily and without a limp)
• Her facial expression (is alert and responsive)
• Her general cleanliness (no visible dirt, no odor)
• Her skin (free from lesions and bruises)
• Her conjunctiva (are pink, not white or very pale pink in color)
• Yellow discoloration of sclera.
2. Height and weight to be taken at first visit and BMI to be calculated
BMI= Weight (Kg) / Height (m2)
3. Measure blood pressure while the woman is seated comfortably in a chair with the knees slightly
bent and relaxed:
• If systolic BP > 140 mm Hg or diastolic BP is >90 mm Hg., ask the woman if she has severe
headache, blurred vision or epigastric pain, and check her urine for protein.
4. Note her Pulse rate, respiratory rate, temperature, pedal oedema and any neck swelling.

Preparing for Further Examination

1. Explain the steps in the physical examination and obtain the woman’s consent.
2. Ask her to empty her bladder and provide urine sample for testing.
3. Have the woman undress in private. Ask her to remove only enough clothing to complete the
examination.
4. Provide her with a drape or cloth to cover the parts of her body that are not being examined.
5. Help her onto the examination surface and assist her in assuming a comfortable position.
6. Visual Breast Examination (First Visit/As Needed)
7. Conduct visual breast examination (First visit/as needed):
• Ask the woman to sit on the examination surface, uncover her body from the waist up, and place
her arms at her sides.
• Visually inspect the overall appearance of the woman’s breasts (contours, skin, nipples and note
any abnormalities)
• If nipples appear inverted, test for protractility by placing the thumb and fingers on either side of
areola and gently squeezing
• If the nipple goes in, it is inverted

Abdominal Examination (Every Visit)

1. Ask the woman to lie on her back with her knees slightly bent and uncover her abdomen from
xiphisternum to pubic symphysis.
2. Inspect the abdomen for condition of skin over abdomen, shape of uterine ovoid,scars and any other
abnormality:
• If there is a scar, look for the site of scar, and ask if it is from a caesarean section or other uterine
surgery, healed by primary or secondary intention.
3. Measure fundal height:
• Centralize the uterus (Correct dextro rotation).
• Place the ulnar border of the left hand on the upper most level of fundus to comment on the
fundal height (Start palpating from xiphisternum and come down till 1 st resistance felt which
denotes uterine fundus.
• If 12–24 weeks, palpate and estimate weeks of gestation by determining distance between top of
fundus and symphysis pubis.
• If 24 weeks and above, use a tape measure to determine the number of centimeters from the upper
edge of symphysis pubis to the top of the fundus.

Assessment of Fundal Height & Its Correlation with Gestational Age

• At 12th week : Just palpable above the symphysis pubis
• At 16th week : At lower one-third of the distance between the symphysis pubis and umbilicus
• At 20th week : At two-thirds of the distance between symphysis pubis and umbilicus
• At 24th week : At the level of umbilicus
• At 28th week : At lower one-third of the distance between the umbilicus and xiphisternum
• At 32nd week : At two-thirds of the distance between the umbilicus and xiphisternum
• At 36th week : At the level of xiphisternum
• At 40th week : Sinks back to the level of the 32nd week, but the flanks are full, unlike that in the
32nd week

UMBILICUS
4. Carry out fundal palpation: (1st Leopold maneuver /Fundal Grip)
• Stand at the woman’s side, facing her head.
• Place both hands on the sides of the fundus of the uterus.
• Using the flat part of your fingers, apply gentle but firm pressure to assess consistency and
palpate the fetal pole occupying the uterine fundus.
5. Carry out lateral palpation: (2ndLeopold maneuver / Lateral Grip)
• Move hands smoothly down sides of uterus to feel for fetal part.
• Keep dominant hand steady against the side of uterus, while using palm of other hand to apply
gentle but deep pressure to explore opposite side of uterus.
• Repeat procedure on other side of uterus.
• Presence of smooth curve denotes presence of fetal back & presence of knobbly parts indicates
fetal limbs.
6. Carry out Pelvic Palpation
A. 3rdLeopold maneuver /2nd pelvic Grip/ Pawlik Grip
• Put ulnar border of the out stretched right hand over pubic symphysis.
• Palpate the fetal pole in the lower uterine segment to identify the presenting part
 Head is felt as hard, smooth & round mass & is more mobile
 Breech felt as soft, broad & irregular mass
 Pelvic grip empty in transverse lie (shoulder presentation)
B. 4thLeopold maneuver / 1st Pelvic Grip
• Turn and face the woman’s feet.
• Place both the hands parallel to inguinal ligament.
• Grasp fetal part snugly between hands to feel shape, size, consistency and mobility.
• Observe the woman’s face for signs of pain/tenderness during palpation.
• Converge fingers of both the hands to see for degree of descent of presenting part.
• If you see the cesarean scar, then elicit the scar tenderness just behind the symphysis pubis,
observe the patient’s face for wincing expression.
7. Place your hand on the body of uterus and feel for uterine irritability/contractions. Also comment
on fetal movement. Painless uterine contractions signify Braxton Hick’s contractions & painful
uterine contraction signify labour pains.
8. Comment on the amount of amniotic fluid
9. Comment on effective fetal weight (EFW) as based on your examination
10. Measure distance between upper border pubic symphysis and mark is made on the fundus Write
the symphysio fundal height in centimeters if pregnancy is > 28 wks.
11. Measure abdominal circulference at the level of the umbilicus in inches. if pregnancy is > 28 wks.
12. Listen to the fetal heart rate by placing the bell of stethoscope on the back of fetus (for full one
minute) counting beats against the second hand of a clock.Feel the woman’s pulse at wrist,
simultaneously, to ensure that you are not listening to uterine suffle.

Genital Examination (First Visit/As Needed)

1. Tell the woman what you are going to do before each step of the examination.
2. Ask the woman to uncover her genital area and cover or drape her to preserve privacy and modesty.
3. Ask the woman to separate her legs while continuing to keep knees slightly bent. Turn on and direct
light toward genital area.
4. Use antiseptic handrub or wash hands thoroughly with soap and water and dry with clean, dry cloth
or allow to air dry.
5. Put new examination or high-level disinfected gloves on both hands.
6. Inspect the external genital for any abnormality
7. Separate labia majora with two fingers of left hand, check labia minora, clitoris, urethral opening,
and vaginal opening.
8. Palpate the labia minora:look for swelling, discharge, nodularity, tenderness, ulcers, and fistulas
9. Per vaginal examination to rule out adenexal mass in uterus or adenexa like leiomyoma, ovarian cyst
or tubal mass and to measure gestational age by estimating the size of the uterus during first
trimester before uterus becomes an abdominal organ.
10. Check perineum for scars, lesions, inflammation or cracks in skin. If patient is primigravida ≥ 38
weeks gestation do pelvic examination to rule out contracted pelvis.
11. PV examination should not be done in cases of bleeding per vaginum at > 20 wks

After the Examination

1. Immerse both gloved hands in 0.5% chlorine solution:
• Remove gloves by turning them inside out
• If disposing of gloves, place in leak proof container or plastic bag
• If reusing gloves, submerge in 0.5% chlorine solution for 10 minutes to decontaminate
2. Use antiseptic handrub or wash hands thoroughly with soap and water and dry with clean, dry cloth
or allow to air dry.
3. Help the woman off the examination table.
4. Share your findings with the woman.
5. Document your findings in the records.

Keep counseling at all levels for:

• Timing and place of next ANC visit based on presence or absence of risk factor
• Rest, nutrition, balanced diet and exercise
• Counseling for HIV testing
• Danger signs
 Institutional delivery
 Birth preparedness
• Early & exclusive breastfeeding for six months
• Contraceptive advice