Antenatal Assessment of Maternal
and Fetal well-being
Written by Rosemary Garratt, Principal Lecturer in Midwifery
Aims

To explore the clinical signs and skills associated with the assessment
of maternal and fetal well-being.

To enhance awareness of the particular skills that may be needed
when care of a woman and her baby becomes more complex.

To practice the skills related to detection of deviation from the normal
and clinical judgement and decision making that is associated with
caring for women with more complex care requirements.

To facilitate discussion and debate in smaller groups in relation to
caring for women with complex needs.
Development 1
How is maternal and fetal well being ascertained in the antenatal
period?

Maternal health influences fetal health

Antenatal history gives clues for risk factors

Referral to specialist clinics and specialist midwives- aimed at optimal
outcomes

Never underestimate interpersonal communication and midwife mother
relationship- trust, rapport, information exchange. Listening and being
sensitive.

Needs continuity in order to work most efficiently

Time limits and availability limits potentially the amount of information that
can be gleaned in order ascertain well-being, especially mental health and
social/psychological issues

Clinical examination
Blood pressure
Urinanalysis
Abdominal examination
Inspection
size and shape, obesity, lax abdominal muscles, multiple pregnancy.
Poly/oliogohydrmanios, fetal size, presentation, lie. shape indication fetal
position (OP) transverse lie?
Skin changes, Fetal movements may be seen
Abdominal palpation
Inspection, palpation, auscultation
Fundal palpation
Fundal height and palpation- landmarks, growth, continuity of carer,
measurement, idea of presentation.
Fundal height inconsistent may indicate:

Unreliable landmarks, long abdomen.

Inaccurate dates

Fetus is larger or smaller than expected

The amount of amniotic fluid may be greater or lesser than
expected

Multiple pregnancy

Abnormal lie

Uterine mass, eg. Fibroid, cyst or tumour.

Poor technique

Intrauterine death
Lateral palpation
Fetal position, confirm lie
Information about the fetal size, amniotic fluid volume, uterine toine
Fetal movements
NICE noted (2003) consider knowledge of fetal position is of limited
relevance until after 36 weeks.
Pelvic palpation
Presentation
Presentation and degree of flexion
If presenting part is engaged in the pelvis
Some indication of size of baby compared with size of pelvis- rough idea- may
give clues. Watch the way women walk!!
How mobile, or moveable the presenting part is if it is not engaged.
Auscultation
If fetal movements are present there is limited value that can be gained from
auscultation of fetal heart on routine visit.
Reassuring to the mother
Heard most clearly through fetal shoulder.
FH 110-160bpm
Assess for:

Presence

Rate

Regularity

Variability

Sonic aid
Chatting
Establishing rapport and trying to link with the woman.
Woman may throw out clues that you need to pick up and explore further.
Women in the scenario have something that they are concerned about or
something that is relevant to their or their baby’s wellbeing- so listen carefully.
Be ready to follow things up, and ask further questions…….
The skill of being a midwife is often about asking the right questions, using
intuition and following up on clinical clues given.
Sometimes there are clues in what is not said or the way that it is said
Scenarios
These are designed to make you think.
They may seem initially straightforward then we will layer levels of complexity
on for you to consider how you would deal with this and what might be going
on.
Aims

To test your decision making skills- when and why you might refer to
the multi-disciplinary team.

Exercise your knowledge of the role and responsibilities of a midwife.

Promoting optimal outcomes for mothers and babies.
Scenario 1: (Student’s copy)
Community Antenatal Clinic
Henrietta Smith Aged 26 years, married to Trevor 30 years. Henrietta is now
30 weeks gestation with her first baby. She has planned a hospital birth in the
Midwifery Led Unit. She has had an uncomplicated pregnancy so far,
suffering only from some morning sickness around 6-11 weeks gestation. Her
Hb is 12.4gm/dl. Blood group O Rhesus positive.
Undertake an antenatal examination to ascertain maternal and fetal wellbeing.
Explain why you are doing things as you go along. Act as though you were
Henrietta’s midwife.
When might you want to see her again?
Scenario 1: (Facilitator’s Copy)
Henrietta Smith aged 26 years, married to Trevor aged 30 years. Henrietta is
now 30 weeks gestation with her first baby. She has planned a hospital birth
in the Midwifery Led Unit. She has had an uncomplicated pregnancy so far,
suffering only from some morning sickness around 6-11 weeks gestation. Her
Hb is 12.4gm/dl. Blood group O Rhesus positive.
Undertake an antenatal examination to ascertain maternal and fetal wellbeing.
Explain why you are doing things as you go along.
When might you see her again?
Henrietta’s story
You are very tired, your husband has his own business (owns local general
store), and you help out in the shop. You have been having uncomfortable
tightenings of your uterus since late last night and they appear to be getting
stronger. You are very concerned that something might be wrong. You have
not felt the baby move much today. You have also had a jelly like
show/vaginal loss this morning. You have backache, and it feels just like
when you are going to start a period.
Scenario 2: (Student’s Copy)
Community Antenatal Clinic
Jane Evans is a 34 year old gravida 2 para1, she is now 34 weeks gestation.
Her pregnancy has been apparently uncomplicated to date. This is the first
time you have met her. You undertake an abdominal examination and on
palpation you assess the fundal height to be 30 weeks gestation.
Undertake Jane’s antenatal examination.
What additional things would you like to ask Jane about in order to ascertain
both maternal and fetal wellbeing?
What action would you take as Jane’s midwife?
When would you see her again?
Scenario 2: (Facilitator’s Copy)
Community Antenatal Clinic
Jane Evans is a 34 year old gravida 2 para1, she is now 34 weeks gestation.
Her pregnancy has been apparently uncomplicated to date. This is the first
time you have met her. You undertake an abdominal examination and on
palpation you assess the fundal height to be 30 weeks gestation.
Undertake Jane’s antenatal examination.
What additional things would you like to ask Jane about in order to ascertain
both maternal and fetal wellbeing?
What action would you take as Jane’s midwife?
When would you see her again?
Jane’s story
Reduced fetal movements for last week.
Has noticed that the baby does not appear to be growing.
Other child has been ill and she has been caring for him.
She has just split up with her husband
She is feeling very stressed and down currently- does not know how she will
cope with a new baby.
Scenario 3: (Student’s Copy)
Eva is 27 years old and she is expecting her fourth baby. She is now 37
weeks gestation. Eva speaks little English. She went into labour at 41 weeks
with all of her previous pregnancies. This pregnancy has been uncomplicated
apart from an Hb of 9.6 gms/dl at booking which has been corrected with the
help of iron tablets. Her Hb is now 11.0gms/dl. She is blood group A Rhesus
negative.
She attends your community based antenatal clinic for a routine appointment.
You have meet her twice before at booking and 28 weeks).
How would you ascertain that both Eva and her baby are well?
What questions would you ask?
How would you communicate to ensure that your questions are understood
and that Eva has the opportunity to ask you/tell you about things that have
been worrying her?
Scenario 3: (Facilitator’s Copy)
Eva is 27 years old and she is expecting her fourth baby. She is now 37
weeks gestation. Eva speaks little English. She went into labour at 41 weeks
with all of her previous pregnancies. This pregnancy has been uncomplicated
apart from an Hb of 9.6 gms/dl at booking which has been corrected with the
help of iron tablets. Her Hb is now 11.0gms/dl. She is blood group A rhesus
negative.
She attends your community based antenatal clinic for a routine appointment.
You have meet her twice before at booking and 28 weeks).
How would you ascertain that both Eva and her baby are well?
What questions would you ask?
How would you communicate to ensure that your questions are understood
and that Eva has the opportunity to ask you/tell you about things that have
been worrying her?
Eva’s story
Eva has been experiencing some abdominal discomfort and has had some
bleeding this morning (around a dessert spoon in terms of quantity). As she
has been sitting in the waiting room the abdominal pain has become worse
and she is now in considerable discomfort. She has noticed that her baby has
not moved much today, which is unusual. She is very worried about her baby
but does not want to make a fuss. Her abdomen feels tender when touched.
She has never disclosed to anyone that her husband is violent towards her,
she is very ashamed about this, and feels very low at times. She has even
thought about taking her own life. Last evening her husband hit her and
kicked her in the abdomen. She has not slept much.
Scenario 4: (Student’s Copy)
Sky is 38 years old and her partner Ray is 28 years old and they are
travellers. They have only recently arrived in this area. They are expecting
their first baby. Sky has had four other children with her previous partner.
You meet Sky and Ray on the delivery suite and have been told to admit her.
Sky has never attended for antenatal care this time around.
She is having abdominal tightenings and thinks that she is in labour.
How would you undertake your antenatal examination and admission?
Remember you will have to act rather like a detective here to ascertain the
clinical picture.
What questions might you ask?
Scenario 4: (Facilitator’s Copy)
Sky is 38 years old and her partner Ray is 28 years old and they are
travellers. They have only recently arrived in this area. They are expecting
their first baby. Sky has had four other children with her previous partner.
You meet Sky and Ray on the delivery suite and have been told to admit her.
Sky has never attended for antenatal care this time around.
She is having abdominal tightenings and thinks that she is in labour.
How would you undertake your antenatal examination and admission?
Remember you will have to act rather like a detective here to ascertain the
clinical picture.
What questions might you ask?
On examination you find:
Bp 110/70 Pulse. 100 bpm Temp. 37ºC
On palpation:
Fundus: 28 weeks
Lie: ? Transverse
Fetal Heart 124bpm
You palpate contractions weak to moderate 1:10. Membranes are intact.
Sky thinks her LMP is 1.11.08, but can’t be sure.
How will you work with the multi-disciplinary team and Sky and Ray to
promote optimal outcomes?
Sky’s story
Sky has had four normal births before all without complications during
pregnancy. She hates hospitals, but has been persuaded to come in today by
worried partner Ray.
Sky has short labours, and although she is only contracting
weakly/moderately currently she knows from experience that things will
progress rapidly when they get going.
She is aware that the baby is currently lying transversely. This baby has been
very mobile throughout her pregnancy.