HIGH RISK SCORING OF
ANTENATAL MOTHER
Submitted to- SUBMITTED BY-
Madam Rakhi Ghosh. Sanchita Samanta
SR. Faculty Teacher Msc(N) 1st year student.
College of Nursing College of Nursing.
Medical college & Hospital Medical College & Hospital.
HIGH RISK SCORING OF ANTENATAL MOTHER
Hospital: Medical college & Hospital Date of Booking: 16/ 02/24 Reg. No. 2400136230
ANTENATAL HISTORY COLLECTION
Name: Rijiya Bibi W/O: Sk. Habibur Ali Age: 21 yrs
Religion: Muslim
Address: Ulughata P.S: Howrah Dist: Howrah
Education Class: class IV pass Occupation: house wife Duration of marriage: 1.5 yrs
HISTORY OF PRESENT PREGNANCY: nothing significant but mother is rh positive with rh
negative husband.
OBSTRETICAL HISTORY: G: 1 P: 0 A: 0 L: 0
Period of gestation in month: 7 months 6 days
History of previous pregnancy: Primi
PAST MENTRUAL HISTORY:
L.M.P: 10/07/23 E.D.D: 17/04/24
Cycle: Regular Dysmenorrhea: Nil
PAST SURGICAL HISTORY: Nothing significant
PAST MEDICAL HISTORY: Nothing significant
PAST HISTORY OF BLOOD TRANSFUSION: Nothing significant
FAMILY HISTORY: Nothing significant
PERSONAL HISTORY: She is non vegetarian and no allergy to food and drug.
GENERAL PHYSICAL EXAMINATION
Pulse : 84 bits/min Respiration: 22 br/min B.P: 124/80 mm of hg.
A. Symptoms
a) Pain: nil
b) Discharge: nil
c) Micturition: frequent
d) Digestion: normal
e) Colic :nil
f) Others symptoms: nil
g) General Health: good
B. Physical Signs
a) Ear & nose: normal
b) Teeth & gum: clean
c) Tonsils & pharynx: normal
d) Breast & Nipple: normal and clean
e) Heart: NAD.
1. f Lungs: NAD.
f) Spleen: not palpable
g) Liver: not palpable
h) Skin: moist
i. Anal region: normal
ii. Valve:normal
iii. Groin: normal
iv. Abdominal wall: striae graviderum
i) Lymphatic: nil
j) General condition: normal
a) Any other sign & symptoms: nil
ABDOMINAL EXAMINATION
Inspection
Fetal movement: present
Skin changes: linia nigra and striae graviderum
Date Fundal height Abdominal Presentation Relative size of FHS/mint
In cm In Girth & position of fetus head to pelvis
weeks
Fundal grip: Not engaged 146bt/min
17/2/24 30 cm 29 wks 84 cm broad ,soft, irregular
mass. Left lateral grip:
smooth curved mass.
right lateral grip: small
knob like structure
PG1: hard globular
mass.
PG2: convergent
presentation: LOA.
Treatment:
Tablet shelcal 1 tab od
Tablet austrin 1 tab od.
Advices:
To take adequate rest & sleep in left lateral position.
To take nutritious diet
To maintain personal hygiene and wear clean clothes.
To take temporary family planning method.
LABORATORY INVESTIGATIONS:
Hb: 11.5gm/dl
Blood group/Type: B (+) ve
VDRL:negetive
Blood sugar: 80mg/dl
HIV: non reactive
Urine: no sugar and albumin
USG: cephalic presentation liquor: adequate
Placenta: posterior lower end encroaching the internal os
BPD- 29 wks 1 days HC- 29 wks FL- 28 wks 3 days AGA- 28 wks 5 days
EFW- 1240gm.
RISK FACTORS Score
1. Age less than 18 yrs or more than 35 yrs 1
2. Maternal height less than 145 cm 1
3. Primi or multi more than five 1
4. Bad obstretical history 2
5. History of neonatal jaundice or Rh incompatibility 2
6. Weight less than 45kg. or more than 90 kg. 3
7. History of low birth weight 1
8. Previous uterine surgery 2
9. History of APH or PPH 2
10.History of manual removal of placenta 2
11.Anaemia (less than 6gm%) 1
12.Febrile ailment in pregnancy 2
13.Pregnancy associated hypertension 2
14.Medical condition with pregnancy 2
15.Bleeding P/V (APH or abortion) 2
16.Abnormal presentation 2
17.Maturity less than 37 weeks or more than 45 weeks 2
18.PROM 2
19.Fetal distress 2
20.Prolonged labor more than twenty hour 2
21.Uterine size less than period of gestation 2
22.Dai handling/ outside interference 2 or 3
Impression: primi, weight less than 45 kg and maternal height is less than 145 cm-3+1+1=5
