Antenatal Examination: A Complete Clinical Guide for BHMS/MBBS Students

1. Definition & Purpose

Antenatal examination refers to the systematic assessment of a pregnant woman at scheduled visits to monitor maternal and fetal well-being.

Objectives:

• Detect & manage pregnancy complications.
• Monitor fetal growth & development.
• Provide maternal education & counseling.
• Prepare for safe delivery.

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2. Schedule of Antenatal Visits (WHO Recommendations)

Gestational Age	Frequency of Visits
Up to 28 weeks	Every 4 weeks
28–36 weeks	Every 2 weeks
36 weeks to delivery	Weekly

• Minimum 8 antenatal visits recommended by WHO.

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3. Components of Antenatal Examination

A. General Examination

Vitals:

• Blood Pressure (BP): Monitor for gestational hypertension, preeclampsia.
• Weight Gain:
• First Trimester: 1–2 kg.
• Second & Third Trimester: 0.5 kg/week (Total ~11–16 kg in normal pregnancy).
  Pallor: Check for anemia (Hb <11 g/dL → Investigate).
  Edema:
• Generalized edema → Preeclampsia.
• Localized (legs) → Normal physiological change.

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B. Abdominal Examination

Inspection:

• Shape & size of the abdomen.
• Striae gravidarum, Linea nigra (Normal changes).

Palpation (Leopold’s Maneuvers):

Maneuver	Purpose
First Maneuver	Determines fundal height & fetal part in fundus
Second Maneuver	Determines fetal lie (Longitudinal, Transverse)
Third Maneuver	Assesses presenting part (Head, Breech)
Fourth Maneuver	Determines engagement of fetal head in pelvis

Fundal Height Measurement:

• 12 weeks: At pubic symphysis.
• 20 weeks: At umbilicus.
• 36 weeks: At xiphisternum.
• After 20 weeks → Fundal height (cm) ≈ Gestational age (weeks).

Fetal Heart Rate (FHR):

• Normal: 110–160 bpm (Measured by Doppler or Pinard stethoscope).
• Tachycardia (>160 bpm) → Fetal distress, Maternal fever.
• Bradycardia (<110 bpm) → Hypoxia, Cord compression.

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C. Pelvic Examination

Performed in Late Pregnancy to Assess:

• Cervical Length & Dilatation (Bishop Score for labor readiness).
• Pelvimetry (If CPD suspected).
• Presence of Vaginal Infections (e.g., Bacterial Vaginosis, Candidiasis).

⚠ Contraindicated in Placenta Previa (Risk of hemorrhage).

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4. Routine Antenatal Investigations

A. First Visit (Booking Visit)

• Complete Blood Count (CBC) → Detect anemia, infection.
• Blood Group & Rh Typing → Prevent Rh incompatibility.
• Urine Routine & Culture → Detect UTI, Proteinuria.
• HIV, HBsAg, VDRL (Syphilis) → Prevent perinatal transmission.
• Random Blood Sugar (RBS) → Screen for Diabetes.
• Thyroid Function Tests (TFTs) → In high-risk cases.

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B. Follow-Up Investigations

24–28 weeks:

• Oral Glucose Tolerance Test (OGTT) → Screen for Gestational Diabetes.

28 weeks:

• Repeat CBC (Check for anemia).
• Anti-D Injection (If Rh-negative mother & Rh-positive fetus).

34–36 weeks:

• Ultrasound for Fetal Growth, Doppler if IUGR suspected.
• Group B Streptococcus (GBS) Screening (If indicated).

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5. Special Screening Tests in Pregnancy

Test	Gestational Age	Purpose
NT Scan & Double Marker	11–14 weeks	Screen for Down Syndrome
Triple/Quadruple Test	15–18 weeks	Detect Neural Tube Defects, Trisomy 21, 18
Anatomy Scan	18–22 weeks	Detect fetal anomalies
OGTT (50g Glucose Test)	24–28 weeks	Screen for Gestational Diabetes
Non-Stress Test (NST)	>32 weeks	Assess Fetal Well-being

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6. Immunization & Supplements During Pregnancy

Tetanus Toxoid (TT) Vaccine:

• 1st Dose: At 16–20 weeks.
• 2nd Dose: At 28–32 weeks.

Iron & Folic Acid (IFA) Supplementation:

• 400 mcg Folic Acid daily (First Trimester → Prevent Neural Tube Defects).
• 60 mg Iron daily (From 12 weeks till postpartum).

Calcium Supplementation:

• 1000–1200 mg/day to prevent pre-eclampsia & osteoporosis.

Vitamin D:

• 600 IU/day to support fetal bone growth.

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7. Danger Signs in Pregnancy

Urgent Medical Attention Required If:

• Severe Headache, Blurred Vision → Preeclampsia.
• Vaginal Bleeding → Placenta Previa, Abruption.
• Severe Abdominal Pain → Ruptured Ectopic, Abruption.
• Absence of Fetal Movements → Fetal Distress.
• Swelling of Hands & Face → Preeclampsia, HELLP Syndrome.

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8. Summary Table: Antenatal Examination

Aspect	Details
Antenatal Visit Schedule	Every 4 weeks till 28 weeks, Every 2 weeks till 36 weeks, Weekly after 36 weeks
Fundal Height Landmarks	12 weeks → Symphysis Pubis, 20 weeks → Umbilicus, 36 weeks → Xiphisternum
Fetal Heart Rate (FHR)	Normal: 110–160 bpm
First Trimester Screening	NT Scan + Double Marker
Second Trimester Screening	Anomaly Scan (18–22 weeks)
Gestational Diabetes Test	OGTT at 24–28 weeks
Immunization	TT Vaccine at 16 & 28 weeks
Danger Signs	Bleeding, No fetal movements, Severe headache

Key Takeaways

• Regular antenatal visits help detect & prevent pregnancy complications.
• Leopold’s maneuvers assess fetal lie & presentation.
• Fundal height estimation correlates with gestational age after 20 weeks.
• Essential screening includes blood tests, OGTT, anomaly scan, and NST.
• Urgent care is needed for bleeding, preeclampsia, or fetal distress signs.