Antenatal Assessment & Urine Analysis

Antenatal Assessment of Pregnant Woman

• The physical examination during pregnancy is a detailed, systematic (head-to-toe) assessment.
• It is done when a pregnant woman attends the antenatal clinic for the first time.

Objectives of Antenatal Assessment

• To assess the woman's overall health status.
• To identify medical and obstetric conditions that may indicate a risk factor.
• To establish a baseline for comparison in subsequent examinations using the obtained information.

Equipment Used

• Stethoscope
• Light measuring device
• Thermometer
• Sphygmomanometer
• Tongue depressor
• Weighing scale
• Uterine testing facility
• Client record

Components of the Antenatal Physical Examination

• Prepare the client care area with necessary supplies and equipment.
  • Ensure visual displays and posters are arranged.
  • Ensure a comfortable waiting area.
  • Ensure educational materials are available.
  • Verify instruments and equipment are available and in working order.
  • Check and balance the scales at the beginning of the clinic.
• Wash hands.
• Greet the woman and her companion respectfully and with kindness, introduce yourself, and offer the woman a seat, to show interest and initiate a good professional relationship.
• Tell the woman what you are going to do, encourage her to ask questions, and listen to what she has to say.
• Explain the importance, schedule, and components of regular antenatal visits.
• Instruct her to empty the bladder and collect a midstream specimen of urine.

Taking History: Personal Information (First Visit)

• Ask the woman's name, address, and available phone number.
• Ask the woman's age, level of education, marital status, consanguinity, duration of marriage, religion, and occupation.
• Ask about housing conditions and crowding index (number of persons/number of rooms).
• Ask about the family's sources of income/financial support.
• Ask if she has received care from another caregiver during this pregnancy.
• Ask if she has access to reliable transportation.

Medical and Surgical History

• Ask about previous blood transfusions (frequency, last date, and cause).
• Ask about previous accidents involving injury to the pelvis.
• Ask about tetanus immunization.
• Ask if she has any allergies to food or drugs, including the name of the allergen.
• Ask if she has been diagnosed with anemia in the last 3 months.
• Ask if she has been diagnosed with syphilis/STDs.
• Ask if she has been diagnosed with any chronic illnesses or conditions, such as TB, heart disease, kidney disease, sickle cell disease, DM, goiter, or any other chronic illnesses.
• Ask about current medications.
• Ask if she has ever been in the hospital or had surgery, such as C.S., genital repair, etc.

Family History

• Ask about any family history of diseases such as DM, hypertension, cardiac disease, multiple pregnancy, congenital abnormalities, and allergic conditions like asthma or eczema, specifying the relation and disease.

Daily Habits and Lifestyle (First Visit)

• Ask if she walks long distances, carries heavy loads, or does heavy physical labor.
• Ask if she gets enough sleep and rest.
• Ask what she normally eats in a day.
• Ask if she is exposed to pregnancy hazards such as caffeine, tobacco, drug use, violence, over-the-counter medications, or exposure to toxins/chemical substances.
• Ask who she lives with and who is the decision-maker.

Obstetrical History (First Visit)

• Details of previous pregnancies, including length, outcome, and numbers.
• Note the date of the last abortion.
• Note problems of each pregnancy.
• Details of previous childbirths.
• Record number, sex, and weight of each newborn (preterm, L.B.W).
• Record problems of each childbirth and modes of delivery such as C.S., tear, or newborn death.
• Details of previous postpartum periods
• Note any contraceptive history.
• Note any complications such as Post-Partum Hemorrhage.
• Ask if she has breastfed and for how long.
• Ask about any problems such as cracked nipples or mastitis.

Menstrual and Contraceptive History (First Visit)

• Ask about age of menarche, duration of menstrual flow, interval of menstruation, amount of menstruation, and any menstrual problems.
• Ask the first day of her last menstrual period (LMP) and calculate her expected date of delivery (EDD).
• Ask how many more children she plans to have.
• Ask if she has used a family planning method before; if so, ask which method she used and whether she liked it.
• Ask if she plans on using a family planning method after this baby is born; if so, ask which method.

Present Pregnancy (First Visit)

• Ask the woman about symptoms of pregnancy.
• Ask if she has felt the baby move.
• If yes, ask when the baby first moved and whether she has felt it move in the last day.
• Ask about her feelings about this pregnancy.
• Ask about the feelings of her partner or family about this pregnancy.

Interim History (Return Visit)

• Remember to ask questions about her present pregnancy at every ANC visit.
• Ask if she has any medical, obstetric, social, or personal problems or other concerns.
• Ask if she has had any problems or significant changes since her last visit.
• Ask if she has received care from another caregiver since her last visit.
• If so, ask who provided the care, what care was provided, and what the outcome of care was.
• Ask if any of her personal information has changed since the last visit.
• Ask if her daily habits or lifestyle (workload, rest, dietary intake) have changed.
• Ask if there has been a change in her medical history since her last visit.
• Ask if she has taken drugs/medication as prescribed and followed the advice/recommendations provided at her last visit.
• Ask if she has had any reaction to or side effects from immunizations or drugs/medications given at her last visit.

Physical Examination (General Examination)

• Observe her general well-being
• Including her gait and movement (walks steadily and without a limp).
• Note her facial expression (alert and responsive).
• General cleanliness (no visible dirt, no odor).
• Check her skin (free from lesions and bruises). Measure accurately woman's weight without shoes to obtain a baseline for comparing weight during pregnancy. Measure accurately her height without shoes to give a baseline for comparing future measurements.
• Measure blood pressure while the woman is seated or lying down with knees slightly bent and relaxed
• If diastolic BP is > 90 mm Hg, ask the woman if she has a severe headache, blurred vision, or epigastric pain and check her urine for protein.
• Measure her pulse.
• Place the woman on the examination couch on her back.
• Drape her and provide privacy. Stand on the right side of the woman.
• Provide privacy (drape the woman and keep doors & curtains closed).
• Examine the head
• Check hair for lice and nits.
• Check the face for pallor, edema, and facial expression to assess anemia, pregnancy-induced hypertension, and psychological problems.
• Check conjunctiva for degree of redness; pallor may indicate anemia.
• Note any pigmentation on the forehead and cheeks.
• Examine the mouth for the condition of gums and teeth.
  • Swelling of the gums may be physiological due to the effect of estrogen.

Examination of the Neck

• Palpate the nodes below the posterior angle of the jaw bones to detect any swelling or tenderness.
  • Swollen, tender nodes may indicate acute infection or cancer.
• Check the neck for the thyroid gland
• Examine the breasts, nipples, and areola to detect any swelling or tenderness.
  • Breast changes begin in early pregnancy. Tenderness is a normal finding in a pregnant woman.
• Examine the abdomen using abdominal grips.
• Examine the extremities for edema by visual inspections and palpation, percussion with a reflex hammer.
• Check the color of palms and nails; pallor may suggest anemia, and cyanosis may indicate chronic cardiopulmonary disease.
• Check for swelling of the fingers.
• Examine the legs, ankles, and feet for shape and unequal length; bent tibia indicates Rickets, and unequal length indicates polymyelitis deformity.
• Check edema over the tibia, ankle, and feet to detect early signs of pregnancy-induced hypertension (P.I.H).
• Observe legs for dilated veins to detect varicosities.
• Assist with pelvic examination.
• Check the woman for danger signs of pregnancy to safeguard the well-being of the mother and her fetus.

After the Examination

• Drape the exposed abdomen.
• Remove gloves by turning them inside out.
• If disposing of gloves, place them in a leak-proof container or plastic bag.
• Help the woman get down from the examination table and put on her clothes.
• Record all findings and the woman's reaction to the exam.
• Return equipment.
• Wash hands.
• Give the woman the necessary instructions and the date of next visit.
• Refer any abnormal finding.

Urine Analysis

• Examination of pregnant women's urine for presence of glucose, protein, blood, or signs of bacteria.

Definition of Urine Analysis for Glucose (Urine Dipstick)

• This test identifies the presence of sugar in urine in trace amounts.

Purpose

• Screening for diabetes in antenatal women and those at risk.
• Evaluating the effect of hypoglycemic agents.
• Identifying the severity of diabetes.

Equipment

• Fresh urine specimen
• Dipsticks
• Gloves

Testing Urine with Urinary Dipstick

• Prepare the equipment and instruments to save time and facilitate the task.

1. Fresh urine specimen
2. Dipsticks
3. Gloves

• Greet the woman warmly and make her feel at ease to gain cooperation.
• Ask the woman to collect urine midstream in a clean specimen cup to prevent infection.
• With gloved hands, pull a dipstick from the bottle.
  • Check the expiration date on the bottle.
• Dip the stick into the urine specimen until all the colored tabs are wet to avoid false results.
• Wait the sufficient time (according to directions on the bottle) for the colors on the stick to change, usually between 30 seconds and 2 minutes.
• Remove the stick, tapping to remove excess urine, and hold it horizontally so urine doesn't drip.
• Compare the colors on the stick to the color chart on the bottle to identify the correct result.
• Remove gloves and wash hands to avoid cross-infection.
• Record findings and compare results from previous appointments, looking for trends.

Examination of Urine for Albumin (Boiling Test)

• This test identifies the presence of albumin in the urine.

Purpose

• To screen for albumin urea in pregnant mothers.
• To test urine for albumin in cases of renal disease or pregnancy-induced hypertension.

Equipment

• A tray containing a test tube, test tube holder, specimen bottle, test tube rack, 1 Sprite lamp, acetic acid, test tube brush, dropper, and gloves.

Procedure: Preparation Phase

• Prepare equipment to save time and facilitate the task.
• Prepare the environment by closing windows and doors and screening the bed to maintain privacy.
• Prepare the patient
  • Assess the condition of the patient and check whether she is taking any medication that will affect urine glucose levels.
  • Explain the procedure to the patient.
  • Cover the purpose of test and what specimen to collect.
  • Explain how to collect the amount to be collected to gain mother cooperation.
• Provide an appropriate container and demonstrate how to use it.
• Instruct the patient not to contaminate the outside of the bottle to avoid cross-infection.
• Remove any secretion/discharge.
• Ask the patient to wash external genitalia with soap and water and then rinse with water alone before collecting a urine specimen.
• Instruct women not to take the first drop or the last drop (first drop is more concentrated and the last drop is low specific gravity, so she must take the middle amount, "mid-stream").
• Wash hands, test tube, and wear gloves to avoid cross-infection

Implementation

• Fill two-thirds (2/3) of the tube with urine and allow it to boil for 2 minutes (the upper part of the tube). Keep the mouth of the test tube away from your face to prevent scalding.
• Assess color.
  • A cloudiness may appear either due to phosphate or albumin, so we add 3-5 drops (drop by drop) of acetic acid.
• If cloudiness disappears (becomes clear) it refers to phosphate, if it does not disappear it refers to albumin.

Evaluation

• Discard urine, remove gloves, and clean the test tube using a brush.
• Return equipment's and return it to its place.
• Record findings and women's reaction in a graphical chart.

Taking History

• A careful history is an important screening tool in assessing reproductive risk and the need for special care.

Objectives

• List components of the woman's history.
• Provide a clinical guide for the physical examination to follow.
• Crucial to establish priorities in the woman's care.

Physical Examination

General Examination

Objectives

• To assess the woman's overall health status.
• To assess medical and obstetric conditions that may indicate a risk factor.
• To use the obtained information as a baseline for comparison at subsequent examinations.

Abdominal Examination During Pregnancy

• Definition: Abdominal examination during pregnancy is a visual, tactile, and/or audible examination of the woman's abdomen. (Done always after 20 weeks) & (Every Antenatal Visit)

Objective

• To confirm pregnancy.
• To estimate the period of gestation.
• To determine presentation, lie, position, and engagement of the presenting part.
• To assess fetal well-being by checking fetal movement and fetal heart sounds.
• To detect any deviation from normal.

Laboratory Tests During Pregnancy

Urine Analysis

• Sugar: Screen for diabetes and evaluate at each visit.
• Albumin: Screen for pre-eclampsia and evaluate for renal problems.
• Urine culture: Diagnose urinary tract infection.

Blood Tests

• Blood urea: Evaluate renal function and diagnose renal diseases.
• Complete blood count: Screen for anemia and iron deficiency.
• White blood cells: Identify infectious processes.
• Rh factor: Alerts care provider to possible incompatibility disease in the fetus.

Others

• Gonorrhea: Diagnoses gonorrhea.
• Cultural of cervical discharge.