Checklist for Investigations in Pregnant Women

1. Do a hemoglobin test (1st visit, then at about 28 weeks, then 34-36 weeks and or when
needed based on signs and symptoms):
• If hemoglobin is <7 g/dL, blood transfusion is indicated. If in-house facility not available,
refer woman to higher centre for it.
• If hemoglobin is between 7–11 g/dL, manage as per the management protocol for anemia
in pregnancy.
2. Do an RPR test /VDRL (first visit):
• If result is positive, refer woman for treatment of syphilis.
• Plan to treat newborn.
• Encourage woman to bring sexual partner for treatment.
• Advise on correct and consistent use of condom to prevent reinfection after treatment.
3. Test for blood group and Rh,. If Rh negative, woman has to be evaluated for the need of
anti-D immune globulin.
4. Test for HBsAg, HCV
5. Inform woman that HIV testing is recommended for all pregnant women, but that she may
choose not to have the test (opt out councelling). If she chooses to be tested, refer her to
counseling and testing services for HIV:
6. Inform about the universal screening needed for gestational diabetes, blood sugar should
be tested by glucometer 2 hours post 75 gram glucose load irrespective of meals . If blood
sugar ≥ 140 mg/dl , treat her as having gestational diabetes (DIPSI criteria)
Do this test at:
• 1st visit/1st Trimester.
• 2nd test at 24-28 weeks – at least 4 weeks after first test
• 3rd test at 32-34 weeks – may be done in high risk cases
7. If she is at high risk of hypothyroidism, recommend serum TSH
8. Urine (Routine and microscopic examination to be done.
9. Obstetric USG (Standard recommendation)
• 1st – 11-14 weeks for NT/NB scan
• 2nd TIFFA at 18-20 weeks (Level –II) for gross congenital malformation
• 3rd at any other time as per indication
If limited facility & only one ultrasound to be done it should be done at 18-20 weeks
 Checklist For History Taking In Pregnant Women

GETTING READY
1. Greet the woman and her companion respectfully and with kindness, introduce yourself,
and offer the woman a seat.
2. Encourage her to ask questions, and listen to what she has to say.

HISTORY
Personal Information (First Visit)
1. Ask the woman’s name, age, address, and phone number (if available).
2. Ask if she has access to reliable transportation.
3. Ask what are her/her family’s sources of income/financial support.
4. Ask if she is having a medical, obstetric, social, or personal problem or other concern,
and if she has had any problems during this pregnancy.
5. Ask if she has received care from another caregiver during this pregnancy.
6. Any History of consanguinity.

Reason for Visit (First Visit)

1. Routine checkup or due to some complaint.
2. If with complaint evaluate complaint in detail.

Obstetric History (First Visit)

1. Number of pregnancies she had before and their outcome
2. Ask if she has had any problems during a previous pregnancy or during/following
childbirth:
• convulsions during pregnancy or during/after childbirth
• caesarean section (indication and post operative complications if any).
• uterine rupture, or uterine surgery during childbirth
• tears through the sphincter and/or rectum during childbirth
• postpartum hemorrhage
• stillbirths, preterm, low birthweight, babies, babies who died before 1 month of age,
h/o congenital anomaly in previous pregnancies.
3. Ask if she had any abortions and if they were spontaneous or induced. Ask for any
complications during abortion.
4. Ask if she has breastfed before. If she has, ask how long she breastfed and whether she
had any problems.

Menstrual History (First Visit)

1. Ask the first day of her last menstrual period and calculate her EDD.
2. Ask if the cycles were regular and for how many days.
3. Ask for h/o heavy menstrual bleeding during menses.

Present Pregnancy (First Visit)

7. Ask about any h/o fever with or without rash, radiation exposure or any over the counter
drugs in first 3 month of pregnancy.
8. Ask if she has felt the baby move. If she has, ask the woman when the baby first moved
and whether she has felt it move in the last day.
9. Ask what her feelings are about this pregnancy.
10. Ask what are the feelings of her partner or family about this pregnancy.

Daily Habits and Lifestyle (First Visit)

1. Ask if she works outside the home.
2. Ask if she walks long distances, carries heavy loads or does heavy physical labor.
3. Ask if she gets enough sleep and rest.
4. Ask what she normally eats in a day, and what she has eaten in the past 2 days. Ask if she
eats any non-food substances such as dirt or clay.
5. Ask if she has had a baby within the last year. If she has, ask if the woman is currently
breastfeeding.
6. Ask if she smokes, drinks alcohol, or uses any other possibly harmful substances.
7. Ask who she lives with.
8. Ask if:
• anyone has ever prevented her from seeing family or friends, stopped her from leaving
her house, or threatened her life.
• she has ever been injured, hit, or forced to have sex by someone.
• she is frightened of anyone.

Medical History (First Visit)

1. Ask if she has any allergies.
2. Ask if she has been diagnosed with anemia in the last 3 months.
3. Ask if she has been diagnosed with syphilis.
4. Ask if she has been diagnosed with any chronic illnesses or conditions such as
tuberculosis, hypertension, epilepsy, heart disease, kidney disease, sickle cell disease,
diabetes, goiter, or another serious chronic illness.
5. Ask if she has any history of blood transfussion.
6. Ask if she has ever been in the hospital or had surgery.
7. Ask if she is taking any drugs/medications (including traditions/local preparations, herbal
remedies, over-the-counter drugs, vitamins, or dietary supplements).
8. Ask if she has had previous history of tetanus toxoid (TT) immunization, how many
injections she has received and when was the last injection given.

Family History (First Visit)

Ask if she has Family history of diabetes, hypertension, genetic disorders/congenital
problems, multiple pregnancy, infections including tuberculosis.

Contraceptive History (First Visit)

1. Ask how many more children she plans to have.
2. Ask if she has used a family planning method before. If she has, ask which method(s) and
whether she liked the method(s).
3. Ask if she plans on using a family planning method after this baby is born. If so, ask which
method.

Interim History (Return Visits). Remember that the questions about her present pregnancy
should be asked at every ANC visit.
1. Ask if she is having a medical, obstetric, social, or personal problem or other concerns.
2. Ask if she has had any problems or significant changes since her last visit.
3. Ask her about quickening or fetal movement.
4. 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.
5. Ask if any of her personal information has changed since her last visit.
6. Ask if her daily habits or lifestyle (workload, rest, dietary intake) changed since her last
visit.
7. Ask if there has been a change in her medical history since her last visit.
8. Ask if she has taken drugs/medications prescribed and followed the dvice/
recommendations provided at her last visit.
9. Ask if she has had any reactions to or side effects from immunizations or
drugs/medications given at her last visit.
 Checklist for calculation of EDD and Period of Gestation
Checklist for how will you calculate the EDD
1. Ask the date of 1st day of last menstrual period.
2. Ask about her menstrual cycles – whether regular or irregular and of how many days.
3. Calculate EDD by adding 9 months and 7 days to the date of first day of last menstrual
period (known as Naegele’s Formula). e.g. if LMP is 4/4/2020 her EDD will be
11/1/2021.
4. This is true for cycles of 28-30 days.
5. If cycles are prolonged or shortened then it must be documented with the EDD, as the
actual EDD will be later or earlier respectively.

There may be some cases where the woman in not able to tell LMP, so the approximate EDD
can be calculated with the help of:

1. Any festival/important event near LMP.

2. If patient is able to tell according to Hindu or Muslim calendar.
3. First USG if done.
4. Time of quickening.
5. First clinical examination particularly if done in first trimester.
6. Time of UPT positive.

Checklist for how will you calculate Period of Gestation

For calculating Gestational age at the time of examination calculate the number of days
from LMP or EDD whichever is nearer and calculate gestational age as total duration of
pregnancy is 40 weeks

For Example:
1. If the LMP is 5/1/2020, EDD will be 12/10/2020.
Now to calculate gestational age on 13/4/2020, the LMP is nearer, so period of gestation
becomes 26 days of January + 29 days of February + 31 days of March + 13 days of
April = 99 days
So period of gestation is 14 weeks 1 day.

2. If the LMP is 1/8/2019, EDD will be 8/5/2020.

Now to calculate gestational age on 13/4/2020, EDD is nearer, so period of gestation
becomes 17 days of April + 8 days of May =25 = 3 weeks 4 days
So period of gestation is (40 weeks) – (3 weeks 4 days) = 36 weeks 3 days.
 CHECKLIST FOR BREAST FEEDING COUNSELING
1. Greet woman, introduce self & establish rapport.
2. Advise woman to start breastfeeding as early as possible and definitely within 1 hour
of delivery & not to give any prelacteal feeds.
3. Counsel her to give exclusive breastfeeding for 6 months
4. Explain to woman about good attachment
• Mouth wide open
• Lower lip turned outwards
• Tongue cupped around breast
• Cheeks round
• More areola above baby's mouth
• Slow deep sucks, bursts with pauses
• Can see or hear swallowing
5. Tell her to face the baby during breastfeeding.
6. Tell her to support her breast with her fingers against her chest wall below her breast
and thumb above.
7. Advise her to breastfeed by both breast, both fore milk and hind milk
8. Tell her to put the baby on shoulder and burp for 10-15 minutes
9. Tell her to feed on demand.
10. Tell her that night feeds are also necessary (minimum 1 feed in night)
11. Explain her if the breast are engorged between feeds then she should empty them
manually in between feeds.
12. Explain advantages of early & exclusive breastfeeding including perfect nutrition,
protection of baby from infection, better mother baby bonding, better health & weight
loss of mother.
13. Among working women, breasts to be pumped and milk stored in refrigerator.
14. Counsel to start complementary feeding at 6 months but to continue breastfeeding for
2 years.
15. Ask for any concerns & address them.
16. Thank the woman & encourage her to return in case of any problem.
 Checklist for patient to be counselled regarding Danger Signs in
Pregnancy
Counsel the woman and her attendants regarding following danger signs

1. Fever
2. Persistent vomiting
3. Convulsions
4. Severe Headache, blurring of vision
5. Generalied swelling of the body and puffiness of face
6. Palpitation, easy fatigability and breathlessness at rest
7. Continuous severe pain in abdomen
8. Vaginal bleeding
9. Decreased urinary output / or burning sensation during micturation.
10. Decreased or absent fetal movements at >28 week.
11. Yellowish discoloration in eyes & palms.
12. Leaking of watery fluid P/V.
13. Itching all over the body.
 Checklist for Birth Preparedness
Definition:

Birth preparedness is advance planning and preparation for delivery. Birth

preparedness helps ensure that women can reach professional delivery care when
labour begins and can also help reduce the delays that occur when women experience
obstetric complications.

Checklist for counseling for birth preparedness

1. Explain to her expected due date and what it means.

2. Enquire for her cultural norms that discourage delivery preparations/planning
3. Enquire what types of preparations are culturally acceptable. How can these
preparations be encouraged and how can they serve as an entry point for
making other important birth preparations.
4. Ask her to identify a birth companion & bring the companion at every antenatal
visit.
5. Evaluate if the woman has any serious risk factors (e.g. medical disorders,
Cesarean section, fistula etc.) that makes it imperative that she delivers in a
higher level health facility.
6. Given her profile, help her choose which health facility she should go to for
delivery.
7. Help her identify which person will accompany her to the facility.
8. a. Help the woman identify how to reach the facility once labour begins,
during day time and during night time hours.
b. How far away is the facility. How long will it take?
c. How much will the trip cost, during the day & at night?
9. Counsel her to identify relations &friends who can donate blood if required
and talk to them.
10. Counsel her to save a little money regularly for expenses at time of birth.
 Checklist for VIA
(Visual Inspection with Acetic Acid)

1. Ensure that appropriate instruments are ready.

2. Explain the procedure to the woman.
3. Request the woman to lie down in dorsal position at the edge of table after
evacuating her bladder.
4. Gently introduce a Cusco’s speculum and open the blades of the speculum
to visualize the cervix in the presence of good light source.
5. Identify the external os.
6. Gently apply 5% acetic acid using a soaked cotton swab on cervix. If
excessive mucus is present remove it by saline moistened swab. The
swabs after use should be disposed of in the yellow bin.
7. Wait for 1 minute.
8. Observe for any acetowhite areas developing on the cervix.
9. Note its location, size and intensity of colour.
10. Remove Cusco’s speculum and put it in 0.5% bleaching solution
11. Discard swab sticks in yellow bin
12. Remove gloves and immerse in 0.5% bleaching solution
13. Wash hands and air dry.
14. Report the result of VIA test and properly document it.
15. Explain the findings to women.
 Checklist for Pap Smear Examination

1. Ensure that appropriate instruments are ready.

2. Explain to the women the reason for performing the Pap smear.
3. Ensure that patient has not used any vaginal medications, had douching,
intercourse, and vaginal examination 24 hours before the procedure
4. Place the patient in the dorsal position at the edge of the table.
5. Wash hands & wear gloves.
6. Insert Cusco’s speculum of appropriate size and visualize the whole of
Cervix.
7. Apply wooden spatula (e.g. Ayer’s Spatula) on ectocervix with the tip in the
external os.
8. Defer procedure if there is any active vaginitis, cervicitis or gross cervical
lesions
9. Rotate by 3600 degree.
10. Make a smear on prelabelled slide and immerse it in 95% alcohol.
11. Remove the speculum & put in 0.5% bleaching solution.
12. Remove gloves and immerse in 0.5% bleaching solution
13. Wash hands & air dry
14. Explain the findings to the women
15. Document & send the slides for cytological examination.