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Prenatal risk assessment: obstetric and biopsychosocial risk, and when the nurse refers

  • Assessment

At every prenatal visit the nurse looks for biological and psychosocial risk, reclassifies the pregnancy and refers at once to a physician when she finds it.

Updated

What it is

Under Res. 3280 de 2018 the risk of every pregnancy is classified at the first visit, from the history, the examination and the tests, and reclassified at every follow-up visit. Women with biopsychosocial risk factors, or with diseases associated with or specific to pregnancy, have a higher risk of maternal and perinatal illness and death and are referred to obstetrics. The resolution recommends the Herrera–Hurtado biopsychosocial scale each trimester. It weighs biological risk together with psychosocial risk (emotional tension and anxiety, and family support). This page names the scale and does not reproduce its items or scores.

Reference values

  • Blood pressure of 140/90 or more on two readings at least 4 hours apart after week 20, or 160/110 or more once: send to a hospital service at once.
  • Inadequate weight gain at week 28: follow-up by a specialised multidisciplinary team.
  • Fundal height below the 10th or above the 90th percentile of the curve: obstetric ultrasound and high-risk assessment.
  • The perinatal record flags a previous newborn under 2500 grams or of 4000 grams or more, three consecutive spontaneous abortions, and less than one year between the last pregnancy and this one.
  • Very high or high risk of venous thromboembolism: inherited or acquired thrombophilia, a previous venous thromboembolic event, sickle cell anaemia.

What you need

  • The perinatal card with the CLAP variables and the perinatal clinical record.
  • The Herrera–Hurtado biopsychosocial scale (Annex 2 of Res. 3280) and the Atalah nomogram for nutritional status.
  • A validated blood pressure device, scale, height rod and tape measure.

How to measure it (and why)

  1. Take the obstetric history: pregnancies and intervals, losses, preterm births, caesareans, haemorrhage, preeclampsia — past events predict risk.
  2. Ask about personal and family disease: hypertension, diabetes, kidney, autoimmune, thrombosis, mental disorders — they define preeclampsia and thrombosis risk.
  3. Assess the psychosocial situation: support, wanted pregnancy, income, displacement, access, ethnicity — these risks do not show on examination.
  4. Ask the violence questions directly — a positive answer activates the route for victims of violence.
  5. Ask the two depression questions and, if either is yes, whether she feels she needs help — detects risk of postpartum depression.
  6. Ask every woman about alcohol and psychoactive substances and offer a brief intervention — even small amounts carry risk.
  7. Apply the Herrera–Hurtado scale and record the result — repeating it each trimester shows how risk changes.
  8. Measure blood pressure, weight and body mass index, fundal height and fetal heart rate, and review the tests — they show new disease.
  9. Classify the risk, record it, refer and confirm that the woman reached the referral — continuity is part of the route.

How to read it

  • Every risk factor raises the risk of maternal and perinatal illness and death above that of the general population; the obstetrician defines the plan of care.
  • If a severe mental illness is present or suspected, care is guaranteed in a specialised mental health service.
  • Risk is not fixed: a woman classified as low risk can become high risk at any visit.

Next step: when to call for help

  • Blood pressure in the referral range: send her to a hospital service now and keep care continuous until she arrives.
  • Headache, visual or hearing changes, epigastric pain, oedema, bleeding, fluid loss, contractions or reduced fetal movements: same-day medical assessment.
  • Positive violence screen: start the route for victims of violence; positive depression screen: medical and mental health assessment.
  • Abnormal test result: report it at once, in a documented way, to the EAPB and refer to a physician.

Test yourself

Think of the answer, then tap the question to see it.

How often is the Herrera–Hurtado biopsychosocial scale applied in Colombia's prenatal care?

In each trimester of pregnancy, as recommended by Res. 3280 de 2018.

Which are three high-risk criteria for preeclampsia in Res. 3280 de 2018?

A previous hypertensive disorder of pregnancy, chronic kidney disease, lupus or antiphospholipid syndrome, type 1 or 2 diabetes, or chronic hypertension.

What does the nurse do when the violence screening questions are positive?

She refers the woman to the comprehensive care route for people at risk of or victims of violence.

At which week are the postpartum depression questions repeated during pregnancy?

At week 28, after the first prenatal visit.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Resolución 3280 de 2018: lineamientos técnicos y operativos de la Ruta de Promoción y Mantenimiento de la Salud y de la Ruta Materno Perinatal (Ministerio de Salud y Protección Social de Colombia, 2018); Sistema Informático Perinatal (SIP): historia clínica perinatal, instrucciones de llenado y definición de términos, 2.ª ed. (Organización Panamericana de la Salud, CLAP/SMR, 2017); Salud sexual y reproductiva: guías para el continuo de atención de la mujer y el recién nacido focalizadas en APS, 3.ª ed. (CLAP/SMR 1577) (Organización Panamericana de la Salud, CLAP/SMR, 2011).

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