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ANTENATAL ASSESSMENT — CASE NO. 5
Filled Example
IDENTIFICATION PROFILE
| Field | Details |
|---|
| Name | Mrs. Priya Sharma |
| W/o | Mr. Rajesh Sharma |
| Age | 24 years |
| Religion | Hindu |
| IP/OPD Registration No. | OPD/2026/1045 |
| Hospital | District General Hospital, Pune |
| Date of Admission/Visit | 13/07/2026 |
| Address | 12, Shivaji Nagar, Pune - 411005 |
Obstetrical Score:
- Gravida: 2 | Parity: 1 | Living: 1 | Abortion: 0
- LMP: 06/01/2026 | EDD: 13/10/2026
- Gestational Period: 28 weeks | Married for: 3 Yrs | Months: 2
HISTORY
- Education: Wife: SSC (10th pass) | Husband: HSC (12th pass)
- Occupation: Wife: Housewife | Husband: Private employee
- Family Income: ₹18,000/month
- Type of House: Pucca | No. of Rooms: 2 | Ventilation: Adequate
- Sanitation Facilities: Attached toilet, piped water supply
FAMILY HISTORY
- Type of family: Nuclear | No. of Family Members: 4 | Adults: 2 | Children: 1
- Hereditary Diseases: No known hereditary diseases
- History of twins: No | Maternal/Fraternal: N/A
- Any other Significant History: Mother-in-law has Type 2 Diabetes
PERSONAL HISTORY
- Sleep: 7-8 hours/night (adequate)
- Appetite: Good
- Allergy: No known allergies
- Habits: No tobacco, alcohol, or substance use
- Addiction: None
- Bladder & Bowel Habits: Normal bladder function; mild constipation (no incontinence)
- Diet: Non-Vegetarian
- Number of Meals a Day: 3 main meals + 2 snacks
- Significant Diet Habits in pregnancy: Increased milk intake, avoids raw papaya and pineapple; takes iron and folic acid supplements
PAST MEDICAL AND SURGICAL HISTORY
Previous Medical Illness and Treatment:
- Childhood illness (Hepatitis/TB/Communicable diseases/Diabetes): Nil
- Thyroid (hypo/hyper) / Asthma / Epilepsy: Nil
- Long term drugs / Blood transfusion: Nil
- Any other significant illness: Mild anaemia in first pregnancy (2023), treated with iron supplements
Any Previous Surgery:
- Abdominal/Pelvic/Orthopedic operation: LSCS (Lower Segment Caesarean Section) in 2023 for fetal distress
Note: This is a simulated teaching example for nursing/midwifery students. All names and details are fictional. The case reflects a common clinical scenario - a 24-year-old G2P1L1 woman at 28 weeks gestation with a previous LSCS, mild anaemia history, and family history of diabetes - all of which are important antenatal risk factors to assess and monitor.This is the continuation (page 37) of the same Antenatal Assessment - Case No. 5 form, covering Menstrual History, Marital History, Obstetric History, History of Previous Pregnancy, and Present Obstetric History. Here is a complete filled example continuing from the previous case (Mrs. Priya Sharma):
ANTENATAL ASSESSMENT — CASE NO. 5 (Page 37)
Filled Example — Mrs. Priya Sharma, 24 yrs, G2P1L1, 28 weeks
MENSTRUAL HISTORY
| Field | Details |
|---|
| Age of Menarche | 13 years |
| Cycle | Regular |
| Interval | 28 days |
| Amount of bleeding (approx.) | Moderate (3-4 pads/day) |
| Treatment taken | No |
| Associated Problems | Mild dysmenorrhoea (resolved after first delivery) |
MARITAL HISTORY
| Field | Details |
|---|
| Marital Status | Married |
| Age at Marriage | 21 years |
| Consanguineous Marriage | No |
| Years of Marital Life (stays with husband) | 3 years |
| Use of Contraceptive | Yes |
| If Yes - Specify Type, Duration, Associated Problems | OCP (oral contraceptive pills) for 6 months after first delivery; stopped 8 months ago to plan second pregnancy |
| Any Treatment for Infertility | No |
OBSTETRIC HISTORY
Past Obstetric History:
- No. of Living Children: 1
- Abortions: 0
- Girls: 0 | Boys: 1 | Spontaneous: 0 | MTP: 0
- Age of First Child: 2 years 6 months
- Age of Last Child: 2 years 6 months
- Any congenital Abnormality/Disease in children: None
HISTORY OF PREVIOUS PREGNANCY
| S.No | Date/Month/Year of Delivery | Pregnancy Events (Pre/Post term/MTP/Abortion) | Labour Events (Prolong/Precipitate/Induction) | Mode of Delivery (N.D./C.S./Instrumental/Indication) | Nature of Puerperium (Complication/Recovery) | Baby (Sex, Birth weight, Immunization, Health) |
|---|
| 1 | Jan 2023 | Full term | Prolonged labour | LSCS (fetal distress) | Normal recovery, no complications | Male, 2.9 kg, fully immunized, healthy |
PRESENT OBSTETRIC HISTORY
| Field | Details |
|---|
| General Health during Present Pregnancy | Fair |
| Complaints during Pregnancy | Mild nausea in 1st trimester (resolved), backache, mild pedal oedema |
| Morning Sickness | Yes (1st trimester only) |
| Minor Ailments | Backache, leg cramps, mild ankle swelling |
| Date of First Visit/Registration for ANC | 10/02/2026 (at 6 weeks) |
| Gestational Age at First Visit | 6 weeks |
| Immunization (TT) | Yes - 1st dose given at 16 weeks |
| Calcium, Iron & Folic Acid supplements during pregnancy | Yes - daily Iron (100mg) + Folic Acid (500mcg) + Calcium (500mg) |
| Any other Medications during pregnancy | Vitamin D3 supplementation |
Clinical Note for Students: This case illustrates a previous LSCS pregnancy (a common high-risk antenatal scenario). Key monitoring points include: scar integrity, mode of delivery planning (VBAC vs repeat LSCS), fetal growth, and anaemia screening given her prior history. The family history of diabetes also warrants a Glucose Challenge Test (GCT) at 24-28 weeks.This is page 38 of the Antenatal Assessment form, covering Antenatal Events during Present Pregnancy (trimester-wise) and the Antenatal Visits/Records table. Here is the filled example continuing with Mrs. Priya Sharma:
ANTENATAL ASSESSMENT — CASE NO. 5 (Page 38)
Filled Example — Mrs. Priya Sharma, 24 yrs, G2P1L1, 28 weeks
ANTENATAL EVENTS DURING PRESENT PREGNANCY
FIRST TRIMESTER (0–12 weeks)
| Field | Details |
|---|
| Morning Sickness | Yes |
| Mild/Moderate/Severe | Mild |
| T/T Taken | Tab. Ondansetron 4mg SOS |
| Bleeding P/V | No |
| T/T Taken | N/A |
| Any other significant problems | Fatigue, mild headache |
| Antenatal Visits/Reports - Height | 154 cm |
| Weight | 52 kg |
| B.P | 110/70 mmHg |
| Sugar | Fasting: 82 mg/dL (Normal) |
| Hb% | 10.2 g/dL (mild anaemia) |
| Urine - Albumin | Nil |
| USG Report/Findings | Single live intrauterine pregnancy, CRL consistent with 8 weeks, no anomaly |
SECOND TRIMESTER (13–28 weeks)
| Field | Details |
|---|
| Minor Ailments (if any) | Backache, leg cramps, mild ankle oedema |
| Any T/T / Medications | Tab. Calcium 500mg BD, Tab. Iron 100mg OD, Vit D3 60,000 IU weekly |
| Hospitalization | No |
| Quickening (Date/Week) | 18 weeks (22/04/2026) |
| Fetal Movements | Present and regular from 18 weeks |
| Any other significant problems | Mild constipation |
| Antenatal Visits/Reports - Height | 154 cm |
| Weight | 57 kg (weight gain 5 kg - appropriate) |
| B.P | 116/74 mmHg |
| Sugar | GCT at 24 weeks: 128 mg/dL (Normal, <140) |
| Hb% | 11.4 g/dL (improving with iron supplements) |
| Urine - Albumin | Nil |
| USG Report/Findings | Anomaly scan at 20 weeks - Normal fetal anatomy, Placenta posterior grade I, AFI normal, previous LSCS scar intact |
THIRD TRIMESTER (29 weeks onwards)
| Field | Details |
|---|
| Minor Ailments (if any) | Mild breathlessness on exertion, increased pedal oedema |
| Any T/T / Medications | Continued Iron, Calcium, Vit D3; Tab. Ranitidine 150mg for heartburn |
| Hospitalization | No |
| Fetal Movements | Good fetal movements, >10/day (kick count normal) |
| Any other significant problems | Nil significant |
| Antenatal Visits/Reports - Height | 154 cm |
| Weight | 61 kg (total weight gain 9 kg so far - within normal range) |
| B.P | 118/76 mmHg |
| Sugar | 88 mg/dL (Fasting - Normal) |
| Hb% | 11.8 g/dL |
| Urine - Albumin | Nil |
| USG Report/Findings | Growth scan at 28 weeks - Fetus in cephalic presentation, EFW 1.1 kg (appropriate for gestational age), AFI 14 cm, LSCS scar intact, no placenta praevia |
ANTENATAL VISITS / RECORDS TABLE
| Date | Ht & Wt | B.P | Gestational Weeks | Fundal Height | Presentation, Position, FHS, Rate | Urine Alb & Sugar; Hb% |
|---|
| 10/02/2026 | 154 cm / 52 kg | 110/70 | 6 weeks | Not palpable | FHS not audible (Doppler: +) | Alb: Nil, Sugar: Nil, Hb: 10.2% |
| 15/03/2026 | 154 cm / 54 kg | 112/72 | 12 weeks | Just palpable | FHS: 148 bpm | Alb: Nil, Sugar: Nil, Hb: 10.8% |
| 20/04/2026 | 154 cm / 56 kg | 114/72 | 18 weeks | 18 cm | Cephalic, FHS: 144 bpm | Alb: Nil, Sugar: Nil, Hb: 11.2% |
| 25/05/2026 | 154 cm / 57 kg | 116/74 | 22 weeks | 22 cm | Cephalic, LOA, FHS: 146 bpm | Alb: Nil, Sugar: Nil, Hb: 11.4% |
| 22/06/2026 | 154 cm / 59 kg | 116/76 | 26 weeks | 26 cm | Cephalic, LOA, FHS: 142 bpm | Alb: Nil, Sugar: Nil, Hb: 11.6% |
| 13/07/2026 | 154 cm / 61 kg | 118/76 | 28 weeks | 28 cm | Cephalic, LOA, FHS: 144 bpm | Alb: Nil, Sugar: Nil, Hb: 11.8% |
Key Points for Students:
- Fundal height (in cm) normally equals gestational age in weeks (±2 cm) - confirmed here
- LOA = Left Occipito-Anterior (normal fetal position)
- FHS (Fetal Heart Sound) normal range: 110-160 bpm
- Total recommended weight gain for normal BMI pregnancy: 11.5-16 kg; this patient is on track
- Hb improving from 10.2 → 11.8 g/dL shows good response to iron therapyThis is page 39 covering Laboratory Investigations and Examination of the Mother. Here is the filled example continuing with Mrs. Priya Sharma:
ANTENATAL ASSESSMENT — CASE NO. 5 (Page 39)
Filled Example — Mrs. Priya Sharma, 24 yrs, G2P1L1, 28 weeks
LABORATORY INVESTIGATIONS
| Date | Investigation | Value in Patient | Normal Values |
|---|
| 10/02/2026 | Hb% | 10.2 g/dL | 11–14 g/dL |
| 10/02/2026 | ABO Rh | B Positive | -- |
| 10/02/2026 | VDRL | Non-reactive | Non-reactive |
| 10/02/2026 | HIV | Non-reactive | Non-reactive |
| 10/02/2026 | HBsAg | Negative | Negative |
| 10/02/2026 | Urine R/E, Alb & Sugar | Alb: Nil, Sugar: Nil, Pus cells: 2-3/hpf | Alb: Nil, Sugar: Nil |
| 15/03/2026 | TC DC | TC: 9,200/mm³, DC: N68 L28 E2 M2 | TC: 6,000–11,000/mm³ |
| 15/03/2026 | BT, CT, PT | BT: 2 min, CT: 5 min, PT: 13 sec | BT: 1–3 min, CT: 3–6 min, PT: 11–13.5 sec |
| 25/05/2026 | Blood Sugar Fasting, PPBS, Random | Fasting: 82, PPBS: 118, Random: 96 mg/dL | Fasting: <100, PPBS: <140, Random: <140 mg/dL |
| 15/03/2026 | Stool R/E | No ova/cysts seen | No ova/cysts |
| 20/04/2026 | TORCH or any other Special Investigations | TORCH screen: Negative; Thyroid (TSH): 2.8 mIU/L (Normal) | TSH: 0.4–4.0 mIU/L |
EXAMINATION OF THE MOTHER
General Appearance
| Field | Finding |
|---|
| Body Built | Average |
| Appearance/Gait | Normal gait, conscious and cooperative |
| Nourishment | Average |
Anthropometric & Vital Signs
| Parameter | Value |
|---|
| Height | 154 cm |
| Weight | 61 kg (at 28 weeks) |
| Temperature | 98.6°F (37°C) - Afebrile |
| Pulse | 84 beats/min, regular, good volume |
| Respiration | 18 breaths/min, normal |
| Blood Pressure | 118/76 mmHg |
Head
| Feature | Finding |
|---|
| Hair - Texture | Soft |
| Hair - Colour | Black |
| Scalp - Cleanliness | Clean, no dandruff or lice |
| Eyes | Mild pallor of conjunctiva (consistent with Hb 11.8%), no periorbital oedema, no icterus |
| Face | No facial puffiness, mild chloasma (mask of pregnancy) present on cheeks |
| Mouth - Teeth | No dental caries |
| Gums | Mild hypertrophy (pregnancy gingivitis) |
| Tongue | Moist, not coated |
| Lips | Moist, mild pallor, no cheilosis |
Neck
| Feature | Finding |
|---|
| Inspection & Palpation - Thyroid Enlargement | No enlargement |
| Lymph Node Enlargement | Not palpable |
Chest
| Feature | Finding |
|---|
| Lungs | Clear, air entry bilaterally equal, no added sounds |
| Heart Sounds | S1 S2 heard, no murmurs |
Breast
| Feature | Finding |
|---|
| Inspection - Symmetry | Symmetrical, enlarged bilaterally (normal in pregnancy) |
| Primary & Secondary Areola | Present, darkened (normal pigmentation changes) |
| Montgomery's Tubercles | Present and prominent |
| Nipples | Erectile, no retraction, no cracks |
| Palpation - Lumps | No lumps felt |
| Presence of Colostrum | Present (expressed on gentle palpation) |
Key Points for Students:
- Mild conjunctival pallor aligns with Hb of 11.8 g/dL - monitor and continue iron therapy
- Chloasma (melasma) is a normal pregnancy finding due to elevated MSH and estrogen
- Colostrum presence from 2nd trimester onwards is normal
- Montgomery's tubercles (enlarged sebaceous glands around areola) are a presumptive sign of pregnancy
- Pregnancy gingivitis is common due to hormonal changes - oral hygiene counselling needed
- All TORCH, VDRL, HIV, HBsAg screening are mandatory antenatal investigationsThis is page 40 covering Abdominal Examination (Inspection, Palpation, Leopold's Maneuvers, FHS Auscultation, Lower Extremities, and Genitalia). Here is the filled example continuing with Mrs. Priya Sharma:
ANTENATAL ASSESSMENT — CASE NO. 5 (Page 40)
Filled Example — Mrs. Priya Sharma, 24 yrs, G2P1L1, 28 weeks
ABDOMEN EXAMINATION
(Exposes the whole abdomen till symphysis pubis)
INSPECTION
| Feature | Finding |
|---|
| Size of Abdomen | Large, corresponding to POG (28 weeks) |
| Shape of Abdomen | Longitudinal, ovoid |
| Contour of Abdomen | Fullness of flanks, firm |
| Umbilicus | Flattened (becoming everted - normal at 28 weeks) |
| Bladder | Not full |
| Skin Changes | Linea nigra present, Striae gravidarum (pink/red stretch marks) present |
| White/Pink Scars | Pfannenstiel scar (lower abdominal transverse scar from previous LSCS) present, well-healed |
| Visible Fetal Movements | Present |
PALPATION
| Parameter | Finding |
|---|
| Abdominal Girth | 84 cm (at umbilicus level) |
| Fundal Height - SFH (Symphysis Fundal Height) | 28 cm |
| Fundal Height in Weeks | 28 weeks (SFH = gestational age, appropriate) |
FUNDAL PALPATION - 1st Leopold's Maneuver (Fundal Grip)
(Identifies lie and presentation)
| Parameter | Finding |
|---|
| Lie | Longitudinal |
| Presentation | Cephalic (hard, round, ballotable mass in fundus = breech/buttocks) |
Broad, soft, irregular mass felt at fundus = Breech (buttocks) confirming cephalic presentation (head is in the pelvis)
LATERAL PALPATION - 2nd Leopold's Maneuver (Lateral Grip)
(Locates fetal back and extremities)
| Parameter | Finding |
|---|
| Position | LOA (Left Occipito-Anterior) |
| Fetal Back | Felt on left side - smooth, firm, continuous resistance |
| Fetal Limbs/Extremities | Felt on right side - irregular, nodular, small parts |
AUSCULTATION OF FHS
(Identify point of highest intensity)
| Parameter | Finding |
|---|
| Rate/min | 144 beats/min |
| Located | Left lower quadrant (LLQ), below umbilicus (LOA position - FHS best heard on same side as fetal back, below umbilicus for cephalic) |
| Character | Regular, clear, fetal heart ticking like a watch |
PELVIC PALPATION - 4th Leopold's Maneuver (First Pelvic Grip)
(Identifies the pole of fetus in the pelvis)
| Parameter | Finding |
|---|
| Free / Engaging / Engaged | Free (head not yet engaged - normal at 28 weeks in multigravida) |
PAWLIC MANEUVER - 3rd Leopold's Maneuver (Second Pelvic Grip)
(Identifies size, mobility, and flexion of presenting part)
| Parameter | Finding |
|---|
| Mobile / Fixed | Mobile |
| Flexed / Deflexed | Flexed (well-flexed head) |
| Fifths Palpable Above Pelvic Brim | 5/5 (completely above brim - not engaged) |
LOWER EXTREMITIES
| Feature | Finding |
|---|
| Varicose Veins | Absent |
| Ankle Edema | Mild pitting oedema (+1) bilateral ankles - physiological (normal in late pregnancy, worse by evening) |
GENITALIA
| Feature | Finding |
|---|
| Excessive Discharge | Mild white physiological leucorrhoea (no itching, no foul smell) |
| Foul Smell / Bleeding / Show | Absent |
| Vulval Edema | Absent |
| Vulval Varicosity | Absent |
Key Points for Students:
- In LOA position, FHS is best heard in the left lower quadrant, below the umbilicus - always confirms with auscultation after palpation
- SFH (cm) = gestational age (weeks) ± 2 cm is a quick bedside screen for fetal growth
- A Pfannenstiel scar from previous LSCS must always be inspected for integrity
- Head not engaged (5/5) at 28 weeks is completely normal, especially in multigravida (engagement may not occur until labour onset)
- Mild ankle oedema is physiological in pregnancy due to venous compression by gravid uterus; pathological oedema involves face and hands
- Leopold's 4 Maneuvers in order: (1) Fundal grip - lie & presentation, (2) Lateral grip - position, (3) Pawlic/2nd pelvic - engagement, (4) 1st pelvic grip - descentThis is the final page of the Antenatal Assessment form covering Drugs Prescribed, Risk Factors, Antenatal Teaching/Advices, and Nursing Care. Here is the completed example for Mrs. Priya Sharma:
ANTENATAL ASSESSMENT — CASE NO. 5 (Final Page)
Filled Example — Mrs. Priya Sharma, 24 yrs, G2P1L1, 28 weeks
DRUGS PRESCRIBED
| Name of Drug | Generic Name | Dosage | Action |
|---|
| Ferrous Sulphate + Folic Acid | Ferrous Sulphate 100mg + Folic Acid 500mcg | 1 tab OD after meals | Treats iron deficiency anaemia; prevents neural tube defects |
| Shelcal 500 | Calcium Carbonate 500mg | 1 tab BD (twice daily) | Prevents hypocalcaemia; supports fetal bone development |
| Vitamin D3 | Cholecalciferol 60,000 IU | 1 sachet weekly | Calcium absorption; prevents maternal/fetal Vit D deficiency |
| Ondansetron 4mg | Ondansetron | 4mg SOS (only if nausea) | Anti-emetic; controls nausea and vomiting |
| Ranitidine 150mg | Ranitidine | 1 tab BD | Reduces gastric acid; relieves heartburn/acidity |
| TT Vaccine (Tetanus Toxoid) | Tetanus Toxoid | 0.5 mL IM - 2nd dose due | Prevents neonatal and maternal tetanus |
ANY RISK FACTORS IDENTIFIED
Risk Factors:
| Category | Details |
|---|
| High Risk | Previous LSCS (scar uterus) - risk of scar rupture, placenta accreta; requires close monitoring and planned delivery |
| Low Risk | Mild anaemia (Hb 11.8 g/dL, improving with treatment); family history of diabetes (GCT normal this pregnancy); mild physiological ankle oedema |
| Remarks | Patient is a known case of previous LSCS - elective repeat LSCS planned at 38-39 weeks. Scar integrity confirmed on USG. Regular ANC follow-up every 2 weeks from 28 weeks onwards advised. |
ANTENATAL TEACHING / ADVICES
| Topic | Advice Given |
|---|
| Nutrition | High protein diet (milk, eggs, pulses, lean meat); iron-rich foods (green leafy vegetables, jaggery, dates); calcium-rich foods (milk, curd, ragi); avoid papaya, pineapple, raw/unwashed foods; drink 8-10 glasses of water daily; small frequent meals to reduce heartburn |
| Follow Up | Visit every 2 weeks till 36 weeks, then weekly till delivery; immediately report danger signs; next visit scheduled on 27/07/2026 |
| Rest & Sleep | 8 hours night sleep + 1-2 hours afternoon rest; sleep in left lateral position (improves uteroplacental blood flow); avoid lying flat on back for long periods |
| Exercise & Work | Light household work allowed; avoid heavy lifting, prolonged standing; gentle walking 20-30 min/day; avoid strenuous activity; no climbing stairs excessively |
| Use of Comfort Devices | Maternity support belt for backache; comfortable flat footwear; loose cotton clothing; pillow between knees while sleeping for backache relief |
| Warning Signs Explained | Advised to report immediately if: severe headache, blurring of vision, epigastric pain, decreased/absent fetal movements, vaginal bleeding, leaking P/V, sudden swelling of face/hands, burning micturition, high fever, severe vomiting |
| Minor Discomforts & Remedies | Backache - rest, posture correction, warm compress; constipation - high fibre diet, adequate fluids; heartburn - small frequent meals, avoid spicy food, sit upright after meals; ankle oedema - elevate legs, avoid prolonged standing |
| Sex | Sexual intercourse is safe in uncomplicated pregnancy; however, advised caution in view of previous LSCS scar; avoid in last 4 weeks of pregnancy; if any bleeding/pain occurs, abstain and report immediately |
| Signs & Symptoms of True Labour | Regular uterine contractions (every 5 min, lasting 45-60 sec, increasing in intensity); show (blood-stained mucus discharge); leaking P/V (rupture of membranes); lower backache radiating to abdomen - report to hospital immediately |
ANY OTHER NURSING PROBLEMS DISCUSSED / NURSING CARE PROVIDED
- Anaemia management - Counselled on importance of regular iron tablet intake, dietary sources of iron, and avoiding tea/coffee with iron tablets (reduces absorption)
- Scar uterus education - Explained significance of previous LSCS scar, need for hospital delivery, danger signs of scar dehiscence (sudden severe abdominal pain)
- Breast preparation for breastfeeding - Nipple care, colostrum significance, importance of early initiation of breastfeeding within 1 hour of delivery
- Birth preparedness and complication readiness - Identified transport, blood donor, birth companion, hospital bag ready by 36 weeks
- Emotional support - Addressed anxiety regarding repeat LSCS; provided reassurance and explained the procedure
- Oral hygiene - Advised on pregnancy gingivitis management; gentle brushing twice daily, dental consultation if worsening
Summary of Case - Mrs. Priya Sharma:
24-year-old G2P1L1 at 28 weeks gestation with previous LSCS (2023), mild anaemia (responding to treatment), family history of Type 2 Diabetes, GCT normal this pregnancy. Currently stable, fetus in cephalic LOA position, FHS 144 bpm, SFH = 28 cm appropriate for dates. Planned for elective repeat LSCS at 38-39 weeks. Regular ANC follow-up every 2 weeks advised.
