Clinical overview
The booking visit is the single most consequential consultation in antenatal care. It is where an undifferentiated pregnant woman is converted into a stratified patient: confirmed pregnant, dated, screened for the conditions that kill mothers and babies in South Africa, and assigned to a level of care that matches her risk. A registrar who treats booking as a paperwork exercise — height, weight, urine dipstick, a bundle of bloods, "see you in a month" — has missed the point. Booking is an evaluation: a structured act of clinical judgement that synthesises history, examination, gestational dating and investigation into a risk formulation and a care plan. The verb in this objective is evaluate, and that is the skill being tested.
The stakes are local and concrete. The Saving Mothers reports (NCCEMD) repeatedly identify the leading causes of maternal death in South Africa as non-pregnancy-related infections (predominantly HIV/TB-associated), obstetric haemorrhage and hypertensive disorders of pregnancy. A disproportionate share of these deaths are judged avoidable, and a recurring contributor is late or poor-quality antenatal care: women booking in the third trimester, undiagnosed hypertension, untreated HIV with high viral loads, anaemia missed until labour. The NDoH National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024) — the SA obstetric source of truth — therefore frames booking not as a tick-box but as the entry point to a risk-stratified pathway. Get booking right and most of the preventable deaths become preventable. This chapter sits alongside sa-maternity-guidelines and feeds the risk work of high-risk-pregnancy-risks.
Figure I2.1 — Booking converts an undifferentiated pregnant woman into a confirmed, dated, screened and risk-stratified patient with a documented care plan and an emergency triage gate.
Core knowledge
Why early booking matters
Several interventions are time-critical and only work if the woman books early. Aspirin prophylaxis for pre-eclampsia is most effective when started before 16 weeks and is recommended from 12 weeks for at-risk women (NICE NG133); first-trimester dating by crown–rump length is far more accurate than later biometry; combined aneuploidy screening (NT + βhCG + PAPP-A) has a defined 11–13⁺⁶-week window; and HIV diagnosis with prompt ART initiation has the greatest effect on mother-to-child transmission when the viral load is suppressed early. The NDoH 5th edition and NICE NG201 both push for booking in the first trimester, ideally by 12–14 weeks. In practice many SA women still book late; recognising and partially salvaging the late booker is itself an examinable skill — see antenatal-screening and gestational-age-assessment.
Levels of care and the basket of antenatal care
South Africa operates a tiered system — primary (clinic / community health centre / midwife obstetric unit), district hospital, regional and tertiary. Booking is usually done at primary level by a midwife using basic antenatal care plus (BANC Plus), the WHO-aligned model adopted nationally that schedules a defined number of contacts (historically eight in the WHO 2016 model) with content specified per visit. The registrar's role is at the referral end: receiving women whom the risk-screen flags, or whose investigations are abnormal, and deciding the appropriate level. A normal-risk multipara does not belong in a tertiary clinic; a woman with a previous classical caesarean, a prosthetic valve, or poorly controlled hypertension does not belong in a clinic. Matching risk to level is the explicit logic of the NDoH guideline.
Dating: the foundation everything else rests on
Accurate gestational age underpins screening windows, growth assessment, the diagnosis of post-dates and preterm labour, and decisions about delivery timing. The hierarchy is: a reliable certain last menstrual period (LMP) in a woman with regular cycles, confirmed or corrected by ultrasound. First-trimester crown–rump length is the most accurate dating measurement; in the second trimester biometry (BPD, HC, FL) is used but is less precise. Standard teaching is to redate by scan when the ultrasound estimate differs from the LMP by more than roughly 5–7 days in the first trimester or about 10–14 days in the second (standard obstetric teaching — exact discrepancy thresholds vary by guideline; follow the local NDoH/ISUOG protocol). The detail and physiology of dating are developed in gestational-age-assessment.
Assessment
This is the weight-bearing section for an evaluate objective. Structure it so nothing is missed.
History
Take a focused but complete obstetric history:
- This pregnancy: LMP, cycle regularity, contraception at conception, planned vs unplanned, any bleeding, pain, hyperemesis, or fever. Folate use pre-conceptionally.
- Past obstetric history: gravidity and parity, each previous pregnancy outcome with gestation and mode of delivery, birthweights, and complications — pre-eclampsia, gestational diabetes, abruption, PPH, preterm birth, stillbirth, shoulder dystocia, previous caesarean and its indication and type of uterine incision. A previous classical (vertical) caesarean is a different beast from a lower-segment one (relevant to vbac and uterine-rupture).
- Medical history: hypertension, diabetes, cardiac disease, renal disease, epilepsy, thyroid disease, mental illness, thromboembolism, sickle/other haemoglobinopathy, and crucially HIV and TB status. Drug history and allergies; teratogen exposure (ACE inhibitors, warfarin, sodium valproate, isotretinoin).
- Surgical / gynaecological history: myomectomy, cone biopsy/LLETZ, uterine anomaly.
- Social history: smoking, alcohol (see substance-use-in-pregnancy), recreational drugs, occupation, housing, food security, intimate-partner violence. Routine sensitive enquiry for IPV is part of respectful, safe care — the linkage between GBV, mental health and pregnancy is covered in gbv-mental-health-pregnancy.
- Family history: diabetes, hypertension, pre-eclampsia, VTE, genetic disease and consanguinity (principles-of-inheritance).
Examination
- General: weight and height → BMI (obesity is a major risk amplifier — RCOG GTG72; underweight and food insecurity matter in the SA setting). Pallor, jaundice, oedema, thyroid, lymphadenopathy. Blood pressure measured correctly with an appropriate cuff is non-negotiable — booking BP establishes the baseline against which later hypertension is judged (hypertension-in-pregnancy, pre-eclampsia-and-hellp).
- Cardiorespiratory: a flow murmur is common; a diastolic murmur, loud systolic murmur, or signs of failure are not — rheumatic and other structural heart disease is an important contributor to SA maternal mortality and warrants referral and echo.
- Abdominal: symphysis–fundal height once the uterus is palpable (roughly from ~20 weeks, correlating loosely with gestation in cm); scars; masses; organomegaly.
- Speculum / pelvic: not routine at every booking but indicated for screening (cervical cytology if due per the SA cervical-screening schedule — cervical-screening-sa) or symptoms (discharge, bleeding).
Investigations — the SA booking basket
The booking bloods and tests, per the NDoH 5th edition, broadly comprise:
Table I2.2 — The South African booking basket grouped by the harm each test prevents and the action it should trigger when abnormal.
| Test | Purpose / SA note |
|---|---|
| HIV test | Provider-initiated, opt-out. Positive → immediate ART (TLD: TDF + 3TC + DTG) and viral-load–driven PMTCT. Repeat testing through pregnancy. See [[hiv-in-pregnancy]], [[hiv-counselling]]. |
| Syphilis (RPR/VDRL or rapid/dual HIV-syphilis test) | Congenital syphilis is preventable and still occurs; treat early. |
| Haemoglobin / FBC | Anaemia is common; iron deficiency the usual cause. Baseline for haemorrhage risk. |
| Blood group + Rh | Rh-negative → anti-D pathway and antibody screen ([[rh-isoimmunisation]]). |
| Rh / red-cell antibody screen | Detects alloimmunisation. |
| Urine dipstick ± MCS | Protein (hypertension/renal), glucose, asymptomatic bacteriuria (treat to prevent pyelonephritis/preterm birth). |
| Rhesus, Hepatitis B (HBsAg) | HBV → neonatal immunoprophylaxis. |
| Glucose screening | Risk-factor-based or universal screening for GDM per protocol (NICE NG3 / local NDoH guidance). |
| Dating ultrasound | Confirm viability, number, dating, gross anomaly. |
| Cervical cytology | If due, per SA schedule (HIV-positive women screened more frequently). |
| TB symptom screen | Cough/fever/night sweats/weight loss — mandatory given TB/HIV burden. |
The exact panel, glucose-screening strategy and antibody-testing intervals should be confirmed against the current NDoH 5th-edition schedule before quoting numbers in an exam — they are periodically revised. Aneuploidy and structural screening (combined first-trimester test, NIPT where available, anomaly scan) are detailed in antenatal-screening and down-syndrome-counselling.
Synthesis: risk stratification
The output of the evaluation is a risk category and a care plan. Ask explicitly: is this pregnancy low-risk (continues BANC Plus at primary level) or does any factor mandate escalation? High-yield escalators include previous caesarean, hypertensive disorder, diabetes, significant medical disease, multiple pregnancy (multiple-pregnancy), previous stillbirth/FGR, BMI extremes, age extremes, and an unsuppressed HIV viral load. The structured list of risk factors lives in high-risk-pregnancy-risks.
Management
Evaluation only matters if it changes management. For each pregnancy, the booking plan should cover:
Routine prophylaxis and supplementation
- Folic acid to reduce neural-tube defects — ideally pre-conception and through the first trimester; higher doses for higher-risk women (previous NTD, certain antiepileptics, diabetes) (standard teaching; confirm dose against NDoH EML). Iron and supplementation principles are developed in pregnancy-nutrition.
- Low-dose aspirin from 12 weeks for women at risk of pre-eclampsia (NICE NG133) — identifying these women is a core booking task.
- Calcium supplementation is recommended in low-calcium-intake populations to reduce pre-eclampsia risk (WHO / NDoH guidance — confirm local protocol).
- Tetanus and other vaccines per schedule (vaccines-in-pregnancy).
HIV — the SA priority
If HIV-positive, start ART the same day (TLD per SA / SAHCS 2023 ART guidelines), check baseline viral load and creatinine, and plan viral-load monitoring through pregnancy to drive the PMTCT and mode-of-delivery decision. If HIV-negative, counsel on retesting and on PrEP where appropriate. This is not an optional add-on: HIV-associated infection is among the leading Saving Mothers causes, and a suppressed viral load is the single most powerful lever on vertical transmission. Detail in hiv-in-pregnancy.
Care plan and counselling
- Assign level of care and book follow-up per BANC Plus.
- Discuss the danger signs every pregnant woman must know: severe headache or visual disturbance, epigastric pain, reduced fetal movements (decreased-fetal-movements), vaginal bleeding, fluid leak, fever, severe vomiting. Make the safety-netting explicit and specific — vague advice is unsafe.
- Address minor complaints (minor-complaints-pregnancy), nutrition, smoking/alcohol cessation, and travel (travel-in-pregnancy).
- Document everything in the maternity case record; this record travels with the woman and is the communication backbone across levels of care.
The emergency overlay — booking is also triage
Booking is not only routine — it can surface an emergency. The drill must be unmistakable:
Figure I2.3 — Danger signs at booking pause routine care: stabilise the mother, start syndrome-specific emergency treatment and escalate before returning to the booking pathway.
If a woman presenting "for antenatal care" has any of these, she is NOT a routine booking — stabilise and escalate immediately:
- BP ≥160/110 with symptoms (headache, visual changes, epigastric pain) or heavy proteinuria → treat as severe pre-eclampsia: IV access, antihypertensive (e.g. oral nifedipine / IV labetalol per protocol), magnesium sulphate if eclampsia/imminent, urgent referral. See pre-eclampsia-and-hellp.
- A seizure → eclampsia: protect airway, left lateral, oxygen, magnesium sulphate loading then maintenance, control BP, deliver after stabilisation.
- Vaginal bleeding in the second half → antepartum haemorrhage: do NOT do a digital vaginal examination until praevia is excluded; IV access, resuscitate, group-and-crossmatch, ultrasound, escalate (antepartum-haemorrhage).
- Reduced or absent fetal movements / no fetal heart → assess urgently (decreased-fetal-movements).
- Signs of sepsis (fever, tachycardia, hypotension) → sepsis-six and escalate.
Knowing when the "booking" patient is actually a resuscitation is exactly the clinical judgement the evaluate verb demands.
Red flags / pitfalls
- Treating booking as clerking, not evaluation. The deliverable is a risk formulation and a plan, not a completed form. Examiners probe the synthesis.
- Anchoring on the LMP in a woman with irregular cycles, recent contraception, or early bleeding, and failing to confirm dating by scan — every downstream decision inherits the error.
- Missing the late booker's compressed agenda. A woman booking at 30 weeks still needs HIV testing, BP, anaemia screening and growth assessment urgently; some windows (aspirin, first-trimester aneuploidy screen) are already shut — say so explicitly rather than pretending the standard schedule applies.
- Normalising a high booking BP. A booking BP ≥140/90 is not "white-coat" until proven; baseline hypertension and early pre-eclampsia must be actively excluded.
- Under-screening for HIV/TB in a high-prevalence setting, or failing to start ART the same day when positive — a missed PMTCT opportunity is a preventable infection.
- Doing a digital VE on an unbooked bleeder before excluding placenta praevia — potentially catastrophic.
- Forgetting the Rh-negative pathway — no antibody screen, no anti-D plan.
- Not documenting danger-signs counselling — the safety net only works if the woman knows what to act on and where to go.
- Wrong level of care in either direction — overloading tertiary clinics with low-risk women, or leaving genuinely high-risk women at primary level.
Evidence anchors
- NDoH — National Integrated Maternal and Perinatal Care Guideline, 5th edition (2024). The South African source of truth for the booking basket, BANC Plus contact schedule, levels of care and referral criteria.
- Saving Mothers / NCCEMD reports (latest triennium). Define the SA leading causes of maternal death (non-pregnancy-related infection incl. HIV, obstetric haemorrhage, hypertension) and the avoidability of late/poor antenatal care.
- NICE NG201 — Antenatal care (2021). Schedule and content of routine antenatal care; early booking, dating, screening.
- NICE NG133 — Hypertension in pregnancy (2019). Low-dose aspirin from 12 weeks for at-risk women; baseline BP and pre-eclampsia risk assessment.
- NICE NG3 — Diabetes in pregnancy. Risk-factor-based gestational-diabetes screening framework (confirm SA glucose-screening strategy against NDoH).
- South African National HIV / ART Consolidated Guidelines (2023) and SAHCS 2023 Adult ART Guidelines. First-line TLD (TDF + 3TC + DTG); same-day initiation; viral-load–driven PMTCT.
- WHO recommendations on antenatal care for a positive pregnancy experience (2016 ANC model). Underpins the BANC Plus multi-contact schedule.
- RCOG GTG72 — Obesity in pregnancy. Risk amplification and management of the high-BMI booking.