During the first and subsequent visits the midwife/doctor should try to determine high risk factors and make timely referral.

Definition: Any pregnancy that is deemed to impose an increased risk to the life or health of the mother or fetus or both during pregnancy.

Identification of High Risk Pregnancy

The criteria for classification as ‘high risk’ pregnancy are as follows:

  • Patients with significant medical conditions such as
    • Hypertension
    • Heart Disease
    • Diabetes
    • Anaemia (including sickle cell anaemia, thalassaemia)
    • Respiratory Disease (e.g. asthma, chronic bronchitis)
    • Epilepsy
    • Thyroid Disease
    • HIV/AIDS
  • History of obstetric complications in a previous pregnancy:
    • Recurrent miscarriages or pre-term births less than 37 weeks
    • Recurrent pre-eclampsia
    • Caesarean Section, myomectomy or hysterotomy
    • Stillbirth or neonatal death
    • Post- partum hemorrhage
    • Fetal congenital abnormality
  • Obstetric complications in present pregnancy:
    • Teenage primipara (16 years and under)
    • Older primipara (over 35 years)
    • Grand multipara (more than 5 pregnancies over 28 weeks gestation)
    • Uterine size inconsistent with period of gestation
    • Antepartum haemorrhage
    • Malpresentation e.g breech; unstable lie
    • Multiple pregnancy
    • Difficulty with palpation of fetal parts, e.g. due to polyhydramnios
    • Other pelvic mass detected
    • Blood group Rhesus negative
    • Post-dates
  • History of substance abuse
  • History of postnatal blues, depression or psychosis
  • Dietary, religious or cultural practices which might adversely affect health status.

Management of ‘High Risk’ Pregnancies

Once a pregnant woman has been identified to be at special risk she should be referred to the Medical Officer to develop a plan of management and to determine the time of referral to hospital.

Indications for Referral to Maternity or other Hospital during Pregnancy

  • All ‘high risk’ pregnancies
  • Severe hyperemesis gravidarum
  • Severe abdominal pain
  • Elevated Blood Pressure with diastolic ≥ 90mm Hg
  • Abnormal blood glucose/diabetes
  • Other medical comorbidity, e.g. HIV, heart disease, sickle cell disease
  • Bleeding/spotting from genital tract
  • Excessive weight gain e.g. ≥ 1 lb (0.5 kg) per week
  • Urinary tract infections – pyelonephritis
  • Excessive amniotic fluid (polyhydraminos)
  • Prelabour rupture of membranes (rupture of membranes before the onset of regular contractions)
  • Fetal heart beat not detected
  • Reduced fetal movements, < 10, over 24 hours


Frequency of visits

  • For a woman with an uncomplicated pregnancy, revisits are suggested as follows:
    • every 4 weeks until 28 weeks;
    • every 2 weeks until 36 weeks;
    • every week from 36 weeks up to delivery.
  • For ‘high risk’ pregnancies, frequency will be determined by the attendant (nurse-midwife, doctor).

Management of Subsequent Visits

  • Take history in order to elicit any change since last visit. Specifically ask about coping with pregnancy, headaches, breast symptoms, swollen extremities, urinary and bowel symptoms, vaginal discharge, fetal movements
  • Test urine, measure weight and blood pressure
  • Perform abdominal examination and record Fundal height, Fetal lie, Presentation
  • Record Fetal Heart Rate (with Doppler from 14 weeks)
  • Continue antenatal education
  • Measure blood hemoglobin every 4 weeks or at least at weeks 28, 32 and 36

At 32-36 weeks

  • Repeat CBC
  • Conduct physical examination
  • Primipara to have a doctor’s assessment
  • Repeat V.D.R.L. and HIV (if negative at the first visit)
  • Write referral to hospital stating all relevant information
  • Consider repeat ulrasound

At 38 weeks

  • Finalize arrangements for delivery
  • Discuss onset of labour
  • Discuss breast-feeding, post-partum care and future contraception.

If the client has not delivered by 40 weeks, a doctor’s evaluation is needed.

Caribbean Public Health Agency © 2014