Prenatal Checkups

Part of Midwifery and Childbirth

What to do at each prenatal visit — the specific examinations, measurements, and assessments that form the backbone of safe pregnancy monitoring.

Why This Matters

A prenatal checkup is not a social call — it is a structured clinical examination designed to detect specific, high-risk conditions at defined times in pregnancy when they are most likely to emerge and most amenable to management. The difference between a productive prenatal visit and an ineffective one is whether the attendant knows what they are looking for, how to look for it, and what to do with what they find.

The history of prenatal care is largely a history of learning which measurements and observations predict poor outcomes. Blood pressure monitoring alone — one simple measurement at each visit — allows early detection of preeclampsia and has prevented more maternal deaths than nearly any other intervention. Fundal height measurement identifies the small percentage of pregnancies with growth restriction or wrong dates that need additional attention. These are not complicated procedures — they are repeatable, teachable, and lifesaving.

This article provides the clinical protocol for prenatal checkups — what to do, how to do it, and how to interpret what you find, organized by the timing of assessment.

The Standard Prenatal Visit Protocol

Every prenatal visit, regardless of gestational age, should follow the same sequence. Consistency builds a longitudinal record that reveals trends.

Visit sequence:

1. Ask about new symptoms or concerns since last visit
2. Measure and record blood pressure
3. Measure and record weight
4. Assess urine (protein, if testing available)
5. Measure fundal height
6. Assess fetal heart rate
7. Assess fetal position (from 28 weeks)
8. Address specific concerns for gestational age
9. Provide education and counseling appropriate to stage
10. Schedule next visit and explain warning signs

Document all findings. A written record is the only way to detect trends across visits — a single blood pressure reading means little; a sequence that shows steadily rising diastolic values is an early warning of impending preeclampsia.

First Visit: Before 12 Weeks

This is the longest and most information-dense visit. Its purpose is to establish baseline data, identify existing risk factors, and confirm the pregnancy.

Establish gestational age: Ask for the date of the last normal menstrual period (first day of the last period). Calculate expected due date: add 280 days (40 weeks) or use the formula — add 9 months and 7 days. Document clearly.

If dates are uncertain (irregular cycles, unknown LMP), gestational age will need to be estimated from physical examination. Uterine size is a reasonable proxy:

• Not yet palpable above pubic symphysis: less than 12 weeks
• Fundus at or just above symphysis: 12-13 weeks
• Fundus midway to umbilicus: 16 weeks
• Fundus at umbilicus: 20 weeks

Blood pressure baseline: Document carefully. This baseline reading determines whether future readings represent elevation from her normal. A woman whose baseline is 100/60 who later reads 130/85 has had a significant rise — important information that would be missed without baseline context.

Medical and obstetric history: Document all previous pregnancies and their outcomes. Each item in the history changes risk assessment:

History finding	Implication
Previous cesarean	Uterine scar — risk of scar rupture; plan for delivery facility
Previous severe preeclampsia	High recurrence risk; monitor closely from early third trimester
Previous postpartum hemorrhage	Prepare uterotonics; birth in equipped location preferred
Previous baby >4 kg	Gestational diabetes risk; monitor growth this pregnancy
Two or more miscarriages	Investigate cause if possible; close monitoring
Previous stillbirth	Increased monitoring; daily fetal movement counting from 28 weeks
Chronic hypertension	Aggressive BP monitoring; higher pre-eclampsia risk
Diabetes mellitus	Gestational management; larger babies; more monitoring
Heart disease	Specialist assessment needed if available

Physical examination:

• General appearance: pallor (anemia), jaundice, swelling
• Thyroid: enlarged thyroid suggests iodine deficiency or thyroid disease
• Heart: auscultate for murmurs — some cardiac conditions are first detected or worsened in pregnancy
• Lungs: normal breath sounds
• Abdomen: uterine size consistent with dates? Scars from previous surgeries?
• Pelvis: in nulliparous (first-time) mothers, clinical pelvimetry (assessing pelvic dimensions) helps identify potential for cephalopelvic disproportion — where the baby’s head may not fit through the pelvis

16 and 20-Week Visits

16 weeks:

• First opportunity to hear the fetal heart with a fetoscope (Pinard horn)
• The fetal heart is typically audible just below the umbilicus midline at 16 weeks, moving to whichever side the fetal back faces as the baby grows
• Fundal height approximately 14-18 cm
• Review nutrition counseling: iron-rich foods, protein intake
• Answer questions about fetal movement (usually first felt 16-20 weeks)

20 weeks — the midpoint assessment: At 20 weeks, a crucial confirmation occurs: the baby’s size and the mother’s dates should agree. Fundal height should be approximately 20 cm.

• If fundal height is >4 cm larger than expected: consider multiple pregnancy, wrong dates (baby earlier than thought), polyhydramnios
• If fundal height is >4 cm smaller than expected: consider wrong dates (baby later than thought), fetal growth restriction, fetal abnormality
• Fetal heart rate should be 110-160 bpm; document where on the abdomen it was heard (indicates fetal position)
• The mother should be feeling fetal movement by this visit — if not, investigate

24 to 28-Week Visits

This is when preeclampsia and gestational diabetes most commonly emerge.

Blood pressure: Any reading ≥140/90 warrants close follow-up or action. Measure blood pressure twice, 30 minutes apart, with the mother resting on her left side between readings.

Signs of preeclampsia to assess beyond blood pressure:

• Protein in urine (dipstick: ++ or more is significant)
• Generalized swelling (hands, face — edema of the ankles is normal in pregnancy; face and hand swelling is not)
• Headache not relieved by rest
• Visual changes (flashing lights, blurring)
• Pain in the right upper abdomen (liver involvement)

Anemia assessment: At 28 weeks, hemoglobin level is typically at its lowest due to blood volume expansion. Clinically assess for anemia: examine the lower eyelid (conjunctiva) — pale pink to white instead of deep pink/red. Examine the gums and tongue for pallor. A woman who appears severely anemic at 28 weeks is at high risk for dangerous hemorrhage at delivery; iron supplementation should be maximized.

Fetal movement: Ask the mother to report any significant change in fetal movement. From 28 weeks, the baby should be moving perceptibly every day. A sudden decrease in movement is associated with fetal distress and requires assessment. Counting: the mother lies on her left side after a meal and counts kicks; 10 movements in 2 hours is reassuring.

32 and 36-Week Visits

32 weeks: Fundal height approximately 30-34 cm. At this point, the baby’s position begins to matter for delivery planning.

Leopold’s maneuvers (assess fetal position): Leopold’s maneuvers are a four-part systematic palpation of the abdomen to determine fetal position.

Maneuver 1 (fundal grip): Place both hands on either side of the fundus. What do you feel?

• Head: round, hard, ballotable (bounces between your hands when tapped)
• Buttocks: broader, softer, irregular, does not ballotte

Maneuver 2 (lateral grip): Move hands to either side of the abdomen. One side will feel firm and resistant (the baby’s back); the other will feel irregular (limbs and knees poking through).

Maneuver 3 (Pawlik’s grip): Grasp the presenting part above the pubic symphysis between thumb and fingers. Confirm what is presenting.

Maneuver 4 (pelvic grip): Face toward the mother’s feet. Place both hands on either side of the lower uterus with fingers pointed downward. Assess how far the presenting part has descended into the pelvis. If the hands can converge: the presenting part is high. If the hands diverge before reaching the pelvis: the presenting part is engaged (head has descended into the pelvic inlet).

36 weeks — birth preparation visit: This is a critical visit for birth planning and final risk stratification.

• Confirm or re-assess fetal presentation: breech at 36 weeks occurs in approximately 3-4% of pregnancies
• Assess engagement: in nulliparous women, head usually engages by 37 weeks; non-engagement at term may suggest disproportion
• Review birth plan explicitly
• Ensure the mother knows warning signs of labor: regular contractions, rupture of membranes, significant bleeding
• Ensure supply kit is prepared
• Confirm who will attend the birth and where

Final assessment questions:

• Is there a support person for labor?
• Is there transport available if needed?
• Is there a plan if something goes wrong?
• Does the mother have emergency contact information?

Documentation and Record-Keeping

A written pregnancy record serves three purposes: it creates a longitudinal trend that reveals patterns, it communicates essential information if the attendant is unavailable at delivery, and it provides a template ensuring nothing is forgotten at each visit.

Minimum data elements at each visit:

Item	Notes
Date and gestational age	Calculate from confirmed LMP
Weight	Track trend
Blood pressure (both readings)	Always record both systolic and diastolic
Fundal height	cm from pubic symphysis to fundus
Fetal heart rate	bpm, location on abdomen
Fetal position	Cephalic/breech/transverse after 28 weeks
Urine protein	If testing available
Concerns raised	What the mother reported
Advice given	What you counseled
Plan	Next visit date and any actions

Even a simple notebook with columns for each data element, maintained consistently across visits, constitutes an effective prenatal record. The information only saves lives if it is written down and reviewed at each visit.