By showing you a scoring system for estimating risk at mid-pregnancy and when labor begins, we can give you an idea of how health care providers routinely assess the chance for complications in pregnancy. As you work through the questions, you should gain a sense of whether you or your baby are at high or low risk for difficulty.

Your score is by no means a sure estimate of possible problems. Complications do occur in low risk women, although less often than those who are considered at high risk. Thus, what you learn from this assessment can only provide you with a rough estimate of your risk. You should discuss any concerns or questions about your chance of complications with your health care provider.

Questions about Previous Pregnancies

Have you ever had a miscarriage or therapeutic abortion?

Yes No (if no, next question can be skipped)

More than one?

Yes No

Have you had five or more children?

Yes No

Have you ever had a child that was stillborn or died within one week of birth?

Yes No (if no, next question can be skipped)

More than one?

Yes No

Have you ever had a caesarean section?

Yes No

Have you ever given birth to a child with a major deformity or genetic problem?

Yes No

Did you have preeclampsia during a previous pregnancy?

Yes No (if no, next question can be skipped)

Was it severe?

Yes No

Have you ever given birth to an infant that was premature (36 weeks or earlier) or that weighed less than 5 pounds?

Yes No (if no, next question can be skipped)

More than once?

Yes No

Have you ever given birth to an infant that weighed more than 9 and a half pounds?

Yes No (if no, next question can be skipped)

More than once?

Yes No

Have you ever gone into labor with the baby not positioned head first?

Yes No

Have you ever had multiples?

Yes No

Are you Rh-negative AND have you had a positive antibody test?

Yes No

Risk Assessment Subtotal score:  #page1total#

Questions about your Current and Past Medical Health

Are you anemic? If so, is your hemocrit between 25 and 32?

Yes No (if no, next question can be skipped)

Lower than 25?

Yes No

Do you have a sickle cell trait?

Yes No (if no, next question can be skipped)

Sickle cell disease?

Yes No

Do you have mild hypertension?

Yes No (if no, next question can be skipped)

Severe hypertension?

Yes No

Do you have heart disease that limits your activity mildly?

Yes No (if no, next question can be skipped)

Severely?

Yes No

Were you a diabetic before this pregnancy?

Yes No

Did you develop gestational diabetes during this pregnancy?

Yes No

Have you ever been treated for thyroid disease?

Yes No

During this pregnancy?

Yes No

Have you ever had gonorrhea, syphilis or genital herpes?

Yes No

During this pregnancy?

Yes No

Have you ever had any bladder or kidney infections prior to this pregnancy?

Yes No

Have you had any this pregnancy?

Yes No (if no, next question can be skipped)

If so, did you have a fever over 100 degrees Fahrenheit?

Yes No

Have you ever been hospitalized for psychiatric reasons?

Yes No

Risk Assessment Subtotal score: #subtotal1#

Questions about Habits and Nutrition

Do you smoke?

Yes No

Do you drink alcohol (including beer and wine) nearly every day?

Yes No

Have you regularly used illegal or illicit drugs?

Yes No

At the time you became pregnant were you more than 20 percent above your ideal weight?

Yes No

Do you weigh more than 200 pounds?

Yes No

Are you more than 10 percent below your ideal weight?

Yes No

Do you suspect that your nutrition has been inadequate this pregnancy?

Yes No

Risk Assessment Subtotal score: #subtotal2#

Questions about this Pregnancy?

Is this your first pregnancy?

Yes No

At the estimated time of your delivery, will you be 15 years of age or younger or 35 years or age or more?

Yes No

Did you seek prenatal care later than 22 weeks, or will you have made fewer than five prenatal visits before delivery?

Yes No

Risk Assessment total score: #finalscore2#