Midwifery (RM)
General Examination of a Pregnant Woman at the Ante-Natal Clinic
General examination is the initial systematic assessment of a pregnant woman using observation, palpation, measurement, and appropriate tools. It establishes baseline health, detects abnormalities, supports nutritional assessment, and guides management.
Purpose
- Obtain baseline maternal data
- Detect and manage abnormalities early
- Assess nutrition and provide individualized health education
Indications
- Initial antenatal clinic assessment
- Routine follow-up examination
- New symptoms, risk factors, or change in maternal condition
Equipment
- Private examination couch and drapes
- Hand-hygiene supplies and gloves
- Thermometer, blood-pressure apparatus, stethoscope, scale, and measuring tape
- Urine and blood investigation supplies when ordered
- Antenatal record and documentation materials
Preparation
- Ask the woman to empty her bladder when appropriate and allow rest before blood-pressure measurement.
- Review previous trends and ensure the examination area is safe and warm.
Procedure steps
- Confirm identity, gestation, consent, privacy, and the reason for examination.
- Observe general appearance, nutrition, hydration, pallor, jaundice, oedema, breathing, mobility, and emotional state.
- Measure and record vital signs, weight, height or relevant anthropometry, and other baseline observations.
- Perform a systematic head-to-toe examination, including cardiovascular, respiratory, breast, abdominal, and extremity assessment as indicated.
- Assess for anaemia, hypertension, infection, malnutrition, diabetes risk, and other danger signs.
- Arrange urine, blood, or other investigations according to the antenatal plan.
- Discuss findings in understandable language and identify health-promotion needs.
- Classify risk, create or update the plan, and refer abnormal findings promptly.
- Ensure the woman is comfortable and has a clear follow-up plan.
- Document measurements, findings, investigations, education, referrals, and response.
Precautions
- Use correctly sized and functioning equipment and repeat unexpected measurements appropriately.
- Protect privacy and dignity, especially during exposure and examination.
- Escalate abnormal vital signs or symptoms immediately rather than waiting for routine review.
- Avoid unnecessary examination and respect refusal.
Aftercare
- Explain findings, arrange investigations or referral, and confirm the next appointment.
- Provide urgent return instructions for danger signs.
Nursing considerations
- Interpret measurements with symptoms and trends, not in isolation.
- Use standard precautions and culturally respectful, woman-centred care.
Patient education
- Explain the purpose of each assessment and encourage questions.
- Teach warning signs, nutrition, hygiene, medication adherence, and follow-up.
Documentation
- Record date, gestation, vital signs, anthropometry, examination findings, investigations, education, risk level, and plan.
- Document abnormal results and the clinician informed.
References and further reading
Educational resource only. Follow current Nursing and Midwifery Council guidance, local institutional protocols, scope of practice, and clinical supervision.
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