• Name: Mrs. __________
• Age: __________ years
• Husband’s Name: Mr. __________
• Address: __________
• Educational Status: __________
• Occupation: __________
• Socioeconomic Status: __________
• Nearest Health Center: __________ (time to reach: ___ mins)
• Transport: __________ (e.g., walking, auto, ambulance)

Gravida (G), Para (P), Live (L), Abortion (A)

Her obstetric index is Gravida ___, Para ___, Live ___, Abortion ___

• Age at menarche: __________
• Cycle: Regular / Irregular
• Duration: Every ___ days, lasting ___ days
• Flow: Moderate / Profuse / Scanty
• Associated symptoms: Clots / Dysmenorrhea
• Last menstrual period: __________ (mention if previous cycles were regular and if oral contraceptive pills were used prior to conception)
• Expected date of delivery: __________
• Period of gestation: ___ weeks ___ days

• Booked / Unbooked
• TT immunization: Number of doses and gestational age at each dose
• Iron and calcium: Yes / No
• Blood group and Rh typing: __________

The various complaints are to be listed in chronological order. Common antenatal complaints include:

• Excessive vomiting
• Swelling of feet
• Bleeding per vaginum
• Leaking per vaginum
• Pain abdomen
• Decreased fetal movements
• Breathlessness
• White discharge per vaginum
• Burning micturition
• Others: __________

If no complaints, state: “The patient has come for routine antenatal check-up or for admission for safe confinement.”

• Describe each symptom by onset, duration, severity, and progression.
• Note any aggravating or relieving factors.
• Mention if patient is currently admitted, with treatment history during this admission.

• Married for: ___ years
• Marriage type: Consanguineous / Non-consanguineous
• If consanguineous, degree: First / Second / Third

Details for each previous pregnancy:

• Confirmed at ___ days of amenorrhea by UPT / USG
• Booked and immunized: Yes / No
• Antenatal events: Uneventful / Complications
• Place of delivery: __________
• Mode: SVD / Instrumental / Cesarean
• Term / Preterm / Postdated
• Onset: Spontaneous / Induced
• Baby status: Live / Stillbirth, Fresh / Macerated
• Sex, weight: __________
• NICU: Yes / No
• Breastfeeding started: ___ hours post-birth
• Exclusive breastfeeding: ___ months
• Child health: __________
• Puerperium: Uneventful / Complications
• Contraception: Method and duration

• Chronic illnesses: Diabetes, Hypertension, TB, Epilepsy, etc.
• Surgical history / Blood transfusion / STDs

• Sleep: Normal / Disturbed
• Appetite: Normal / Decreased
• Addictions: Tobacco / Alcohol / Smoking
• Drug allergies / Long-term medications
• Diet: Mixed / Vegetarian
• Calorie intake: ___ kcal/day
• Protein intake: ___ g/day
• Adequacy: Adequate / ___% deficient (calories and/or protein)

• Diabetes, Hypertension, Tuberculosis
• Congenital anomalies, Multiple pregnancies
• Genetic disorders

Summary should include:
- Name: __________, Age: ___ years
- Obstetric index: Gravida ___, Para ___, Live ___, Abortion ___
- Last menstrual period: __________
- Expected date of delivery: __________
- Period of gestation: ___ weeks ___ days
- Chief complaints: __________
- Notable findings from obstetric, medical, personal and family history
- Risk categorization: Low-risk / High-risk pregnancy

• Weight and height measuring tools
• Knee hammer
• Inch tape
• Stethoscope
• Sphygmomanometer
• Thermometer

• Patient comfort at rest: __________
• Build: Thin built / Medium built / Well built
• Nourishment: Adequate / Poorly nourished
• Height: __________ cm
• Weight: __________ kg
• Body Mass Index (BMI): __________ (Use pre-pregnancy or early first trimester weight)
• Abnormal gait: __________
• Spinal deformities (e.g., kyphoscoliosis): __________
• Signs:
• Pallor: Present / Absent
• Icterus: Present / Absent
• Cyanosis: Present / Absent
• Clubbing: Present / Absent
• Lymphadenopathy: Present / Absent
• Pedal edema: Present / Absent

Note: Presence or absence of pallor and pedal edema should be recorded at every antenatal visit.

• Temperature: __________ (Afebrile / Febrile — if febrile, specify: _____ °C / °F)
• Pulse Rate: __________ /min
  • Rhythm: __________ (e.g., regular)
  • Volume and Character: __________ (e.g., normal)
  • Peripheral Pulses: __________ (e.g., all peripheral pulses equally felt)
• Respiratory Rate: __________ /min
• Blood Pressure (BP): __________ mmHg
  • Measured in: Right Upper Limb
  • Position: Sitting / Left lateral

• Thyroid Status: __________ (e.g., Normal / Swelling present)
• Movement with Deglutition: __________ (Yes / No)

• General Appearance: __________ (e.g., Normal)
• Retracted Nipple: __________ (Present / Absent)
• Fissures: __________ (Present / Absent)
• Discharge from Nipple: __________ (Present / Absent)
• Palpable Mass: __________ (Present / Absent)

• Cardiovascular System (CVS): __________
  • e.g., "Clinically normal" / "S1 S2 heard and no murmurs" / "Within normal limits"
• Respiratory System (RS): __________
  • e.g., "Clinically normal" / "Normal vesicular breath sounds heard" / "Crepitations, rhonchi, diminished breath sounds" etc.

Prerequisites:

• Explain procedure to patient
• Obtain consent
• Ensure bladder is emptied
• Ensure privacy (e.g., use of screen)
• Adequate lighting
• Stand on the right side of the patient
• Presence of female attendant if examiner is male
• Patient positioned supine; lower limbs covered
• Expose only the area to be examined
• Warm hands; examine from non-tender to tender areas

• Abdominal distension and contour: __________
• Flanks: __________ (e.g., Full / Not full)
• Umbilicus: __________ (e.g., Normal / Everted / Flushed)
• Linea nigra: __________ (Present / Absent)
• Striae gravidarum: __________ (Present / Absent)
• Scars/Sinuses: __________
• Cough impulse at hernia orifices: __________ (Present / Absent)
• Cough impulse at scar sites (if any): __________ (Present / Absent)

• Fundal Height:
  • Patient position: Dorsal position with legs flexed and slightly abducted
  • Correct dextrorotation of uterus using the right hand
  • Palpate fundus using the ulnar border of the left hand
  • Technique:
    • From below upwards: Feel until resistance of uterus disappears
    • From above downwards: Feel until resistance of fundus is encountered
  • Before removing the palpating hand, ask for patient’s permission
  • Mark the fundal height on the abdomen
• Symphysiofundal Height (SFH):
  • Patient position: Dorsal position with legs extended
  • Use measuring tape with inches side facing upward
  • Place one end at the pubic symphysis
  • Extend tape across umbilicus to the marked fundal height
  • Turn tape to read SFH in centimeters

Note: SFH is the only measurement done with the patient’s legs extended. This ensures consistent reference from the pubic symphysis at every visit.

Aim: To determine fetal lie and presentation. Grips are usually performed after 34 weeks of gestation.

• Patient position: Dorsal position with legs flexed and slightly abducted
• Ensure uterus is relaxed
• Palpate gently using the ventral aspect of fingers
• Examiner faces the head end of the patient for the first three maneuvers and the feet end for the fourth maneuver

1. Fundal Grip (First Leopold’s Maneuver):

• Examiner faces the head end of the patient
• Palpate the uterine fundus with both hands
• Inference:
  • Ballotable, smooth, hard, globular mass → Fetal head
  • Broad, soft, irregular, nonballotable mass → Breech

2. Lateral/Umbilical Grip (Second Leopold’s Maneuver):

• Examiner faces the head end of the patient
• Steady one side of uterus while palpating the other, then switch sides
• Inference:
  • Smooth, curved, uniform resistance → Fetal back
  • Small, knobby, irregular parts → Fetal limb buds

3. First Pelvic Grip / Pawlik’s Grip (Third Leopold’s Maneuver):

• Examiner faces the head end of the patient
• Place the ulnar border of the right hand above the pubic symphysis
• Palpate presenting part between thumb and fingers
• Inference:
  • Ballotable, smooth, hard, globular mass → Fetal head
  • Broad, soft, irregular, nonballotable mass → Breech
  • Freely ballotable part → Not engaged
  • Fixed or nonballotable → Possibly engaged
  • Note: In transverse lie, this grip feels empty

4. Second Pelvic Grip (Fourth Leopold’s Maneuver):

• Examiner faces the foot end of the patient (only maneuver performed this way)
• Performed usually at term to check engagement of presenting part
• Place both hands above and parallel to the inguinal ligament on either side of abdomen
• Palpate simultaneously, moving medially and downwards
• Inference:
  • Confirms findings of first pelvic grip: fetal presentation and engagement
  • Additional info on fetal head attitude (flexed/deflexed/extended in cephalic presentation)

Following Obstetric Grips:

• Uterine Activity: __________ (e.g., Relaxed / Irritable / Acting)
• Liquor Content: __________ (e.g., Average / Excessive / Reduced)
• Scar Tenderness:
  • To be assessed in previous cesarean cases to rule out scar rupture
  • Palpate suprapubic region with palmar aspect of fingers
  • Observe patient's face for signs of pain or discomfort

• Locate FHR on the side of fetal back along the spinoumbilical line
• Use bell of stethoscope for auscultation
• Count for 1 full minute
• Normal FHR: 120–160 beats per minute
• Note:
  • FHR is heard best through:
    • Fetal back (left scapular region) in vertex and breech
    • Fetal chest in face presentation

• Formula: Johnson’s formula → (SFH - 11 or 12) × 155 grams
• Subtract 11 if head is below ischial spines
• Subtract 12 if head is at or above ischial spines

Note: Not routinely done in antenatal period. Indicated for complaints like vaginal discharge, pelvic pain, or at/after 38 weeks.

• Performed to assess cervix, presenting part, membranes, and pelvis (when indicated)
• Undergraduates: Only perform abdominal and external genital inspection
• Postgraduates: Expected to perform full pelvic exam in indicated cases

Prerequisites:

• Ensure patient empties bladder
• Explain procedure and obtain informed consent
• Ensure privacy and adequate lighting
• Position: Dorsal position with thighs flexed and slightly abducted, buttocks at edge of table
• Wash hands and wear sterile gloves
• Swab vulva and perineum with Savlon or Betadine before examination

Note: Performed only when indicated (e.g., vaginal discharge, pain, or post 38 weeks gestation). Undergraduate students perform only external inspection. Postgraduates are expected to perform full pelvic examination when required.

• Inspection of External Genitalia:
  • Inspect mons pubis, labia majora, labia minora, perineum, and anal region
  • Check for ulcers, warts, skin lesions, varicosities, or vulvar edema
  • Separate the labia to inspect urethra, clitoris, and vaginal introitus
• Speculum Examination:
  • Performed before bimanual or vaginal examination
  • Use Sims’ speculum or Cusco’s bivalve speculum under aseptic precautions
  • Use a good light source to visualize vagina and cervix
  • Check for:
    • Abnormal vaginal discharge
    • Leaking per vaginum (P/V)
    • Bleeding per vaginum (P/V)
    • Ulcers or lesions on cervix or vaginal wall
  • Take cervical smear for exfoliative cytology (PAP smear) or vaginal swab for culture if indicated

• Performed in early pregnancy when the uterus is still a pelvic organ.
• Index and middle fingers of the examiner’s right hand are introduced into the vagina.
• Left hand is placed in the suprapubic region to palpate the uterus between both hands.
• Note the following:
  • Cervix: Consistency, position, and any cervical pathology
  • Uterus: Size, shape, position, and consistency (correlate with period of amenorrhea)
  • Adnexae: Any mass or tenderness felt through the fornices

• Usually indicated before induction or during labor.
• Purpose:
  • Pelvic assessment to rule out cephalopelvic disproportion (CPD)
  • Assess cervical ripening before induction
  • Assess fetal presenting part and position
  • Perform artificial rupture of membranes (ARM)
  • Note color of liquor (if membranes are ruptured)
  • Rule out cord prolapse
  • Assess cervical effacement and dilatation during labor
  • Determine station of presenting part
  • Monitor progress of labor
  • Confirm second stage of labor

A brief summary of the history and examination should include:

• Patient’s name and age
• Obstetric index (G, P, L, A)
• LMP, EDD, POG
• Chief complaints
• Relevant positive and negative history
• Complications, if any
• Salient general and obstetric examination findings

A provisional diagnosis should summarize the patient’s condition:

• Age
• Obstetric index
• POG
• Associated complications (if any)
• Current pregnancy status

Example: 26 years of age, G2P1L1A0 at 34 weeks of gestation, with a singleton live fetus in cephalic presentation, not in labor.