Antenatal Risk Assessment 

This is an evaluation carried out on pregnant women during the antenatal period to screen them from  the probability of these women who are likely to develop poor pregnancy outcome during childbirth, detection and management of any illness or pregnancy complications as they arise.

First Antenatal Visits/Booking Visit 

The purpose of this visit is to obtain the baseline information against which subsequent findings  in a woman will be assessed. 

This baseline information is obtained through:- 

1. ✔ History taking 
2. ✔ Physical taking – General, systemic and abdominal examination 
3. ✔ Investigations 

1. History taking 

This is done in a proper and orderly manner to assess the health status of the mother and  fetus. 

History must include:- 

• ✔ Name and place of residence, noting accessibility to medical and maternity care 
• ✔ Age: noting the high risk age of below 18 and above 35 years 
• ✔ Parity: noting the young and elderly primigravida, those above Para 4 and closely  spaced pregnancies (>2 years in between) 
• ✔ Social history, inquire whether married, source of social and financial support,  education status, genital mutilation, where applicable, alcohol, smoking, health of  partner.  
• ✔ Medical history e.g. hypertension, renal disease, epilepsy, diabetes mellitus, sickle  cell disease, asthma, TB and HIV, surgical history, operation, blood transfusion,  skeletal deformity, fractures of pelvis, spine and femur. 
• ✔ Obstetric and gynecological history, inquire about previous pregnancy and their  outcomes such as previous cesarean section, previous retained placenta, PPH, still  birth, prolonged labour and early maternal death, ectopic pregnancies, D & C , APH,  pre-eclampsia etc. 
• ✔ Family e.g. history of hypertension, diabetes in her family, twins, sickle cell disease.
• ✔ Menstrual history:- 

1. – Information on the woman‘s‘ menstrual history is obtained and recorded  e.g. age at menarche, length and regularity of the cycle, duration and  amount of menstrual flow. 
2. – Contraceptive history e.g. use of modern contraceptive methods and dates  of discontinuation should be noted. 

• ✔ History of present pregnancy:- Information regarding the first day of LNMP is obtained and the expected  date of delivery (EDD) calculated. This will guide the provider during  examination to compare the weeks of amenorrhea with the height of fundus. If pregnancy is over 20 weeks, dates of quickening should be noted. Any problems encountered since she became pregnant should be probed into and noted e.g.  bleeding, vomiting, hospitalization, HIV sero-status and diseases like fever,  cough, and diarrhea. 

2. Physical examination 

General  

A physical examination from head to toe should be performed and note nutritional state and  illness which may not be related to pregnancy:- 

• ✔ Measure the weight, noting those that are underweight or over- weight (below 45  Kg and above 80 Kg) 
• ✔ Measure height and note those below 159Cms and check for skeletal deformities  or limping. 
• ✔ Take blood pressure- note those with BP 140/90 mmHg and above 
• ✔ Check for anemia and jaundice by examination of the conjunctiva, tongue, palm  of the hand and capillary refilling in the nail beds 
• ✔ Check for oedema of feet, hands, face and sacral area 
• ✔ Carry out a systematic examination of the respiratory and cardiovascular systems  to exclude abnormalities. 
• ✔ Examine breasts for possible masses and signs of breast malignancy, educate  women to care the nipples and teach herself breast examination 
• ✔ Assessment of physical abuse: 

1. – Drug abuse 
2. – Bruising 

• ✔ Assessment of any complaints 

3. Abdominal examination 

The abdomen should be adequately exposed to show important landmarks. 

1. ✔ Inspect the abdomen and note: 

• – size, shape of abdomen and presence of scar that may indicate a previous  uterine operation 
• – presence of fetal movements 

       2. ✔ Palpation of abdomen noting: 

• – presence of enlarged liver, spleen and tenderness of renal angles 
• – Height of fundus and compare it with the weeks of gestation. excessive  enlargement of abdomen, maybe an indication of multiple pregnancy or  presence of polyhydramnios 
• – The lie, presentation, position, any tenderness and the amount of liquor. 

        3. ✔ Auscultation. listen to fetal heart noting the rate, volume and rhythm

Inspection of the vulva 

This should be done to detect lesions of the vulva, vagina and abnormal discharge. Note any  scars at the perineum or vulva. If an abnormal discharge is detected and there are facilities for  gram stain, take of specimen for analysis. If there are no laboratory services, use the STI  ―syndromic approach to provide treatment to the mother. 

Laboratory Investigations during Antenatal Care 

Baseline investigations: 

• – Hb (normal 10.5-15gm) 
• – Blood group (ABO and Rhesus factor) 
• – Urinalysis (protein and sugar) 
• – VDRL, RPR for syphilis 

Special Investigations (Refer When Necessary) 

1. – Rhesus antibodies for RH-ve mothers 
2. – Random blood sugar where there is a history or presence of glycosma 
3. – Mid-stream urine for culture and sensitivity 
4. – High vaginal swab (HVS) 
5. – Elisa test for HIV 
6. – Sickling test 

Others 

• – Provide TT to complete the recommended schedule for immunization against tetanus. this  is routinely done to protect the mother and neonate from tetanus 
• – Explain to the mother the importance of tetanus immunization 

Recording, Assessing Findings and Planning For Management 

• ✔ After examination, all finding should be recorded on ANC clients‘ card and register 
• ✔ Review findings on history, examination and investigations 
• ✔ Share plans for next steps 
• ✔ If the woman has to be referred, a referral note should be filled, handed to the client and  she should be explained on where to go for further management 

The health worker should refer a client/patient to health facility that is able to handle the types of  obstetric condition identified to avoid wastages of time and transport costs encountered by the  patient/family. The health worker with assistance of relatives should organize quick means of  transport. A relative/health worker escorts the mother where applicable.